pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	mrx_tier_id	mrx_tier_benefit_type	mrx_tier_type_id	mrx_tier_lbl	mrx_tier_drug_type	mrx_tier_includes	mrx_tier_spec_yn	mrx_tier_gap_cost_share	mrx_tier_gap_drug_type_lmtd	mrx_tier_gap_all_drug_yn	mrx_tier_lbl_5	mrx_tier_locat	mrx_tier_inp_1m_num	mrx_tier_inp_3m_num	mrx_tier_inp_othnum	mrx_tier_inpp_1m_num	mrx_tier_inpp_3m_num	mrx_tier_inpp_othnum	mrx_tier_innpp_1m_num	mrx_tier_innpp_3m_num	mrx_tier_innpp_othnum	mrx_tier_oonp_1m_num	mrx_tier_oonp_othnumn	mrx_tier_mo_1m_num	mrx_tier_mo_othnum	mrx_tier_mopp_1m_num	mrx_tier_mopp_3m_num	mrx_tier_mopp_othnum	mrx_tier_monpp_1m_num	mrx_tier_monpp_3m_num	mrx_tier_monpp_othnum	mrx_tier_mo_3m_num	mrx_tier_ltcp_1m	mrx_tier_lbl_4	mrx_tier_ref_price_yn	mrx_tier_cstshr_struct_type	mrx_tier_lbl_2	mrx_tier_inp_coins_1m	mrx_tier_inp_coins_3m	mrx_tier_inp_coins_othnum	mrx_tier_inpp_coins_1m	mrx_tier_inpp_coins_3m	mrx_tier_inpp_coins_othnum	mrx_tier_innpp_coins_1m	mrx_tier_innpp_coins_3m	mrx_tier_innpp_coins_othnum	mrx_tier_oonp_coins_1m	mrx_tier_oonp_coins_othnum	mrx_tier_mo_coins_1m	mrx_tier_mo_coins_3m	mrx_tier_mo_coins_othnum	mrx_tier_mopp_coins_1m	mrx_tier_mopp_coins_3m	mrx_tier_mopp_coins_othnum	mrx_tier_monpp_coins_1m	mrx_tier_monpp_coins_3m	mrx_tier_monpp_coins_othnum	mrx_tier_ltcp_coins_1m	mrx_tier_lbl_6	mrx_tier_inp_copay_1m	mrx_tier_inp_copay_3m	mrx_tier_inp_copay_othnum	mrx_tier_inpp_copay_1m	mrx_tier_inpp_copay_3m	mrx_tier_inpp_copay_othnum	mrx_tier_innpp_copay_1m	mrx_tier_innpp_copay_3m	mrx_tier_innpp_copay_othnum	mrx_tier_oonp_copay_1m	mrx_tier_oonp_copay_othnum	mrx_tier_mo_copay_1m	mrx_tier_mo_copay_3m	mrx_tier_mo_copay_othnum	mrx_tier_mopp_copay_1m	mrx_tier_mopp_copay_3m	mrx_tier_mopp_copay_othnum	mrx_tier_monpp_copay_1m	mrx_tier_monpp_copay_3m	mrx_tier_monpp_copay_othnum	mrx_tier_ltcp_copay_1m
H0046	001	0	1	04	01	H0046_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	4.00	8.00								4.00											4.00
H0046	001	0	1	04	01	H0046_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	14.00	28.00								14.00											14.00
H0046	001	0	1	04	01	H0046_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	80.00								40.00											40.00
H0046	001	0	1	04	01	H0046_001_0	6	4	4	3	Specialty	100001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0046	001	0	1	04	01	H0046_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0046	001	0	1	04	01	H0046_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0046	001	0	1	04	01	H0046_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	4.00	8.00								4.00											4.00
H0046	001	0	1	04	01	H0046_001_0	6	4	4	1	Specialty	100001	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	25	25								25											25	Specialty																					
H0084	001	0	1	04	01	H0084_001_0	9	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
H0084	001	0	1	04	01	H0084_001_0	9	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	75.00	225.00								75.00		75.00	225.00								75.00
H0084	001	0	1	04	01	H0084_001_0	9	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
H0084	001	0	1	04	01	H0084_001_0	9	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	38.00	114.00								38.00		38.00	114.00								38.00
H0097	002	0	1	09	04	H0097_002_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0097	002	0	1	09	04	H0097_002_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0097	002	0	1	09	04	H0097_002_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H0097	002	0	1	09	04	H0097_002_0	8	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H0097	002	0	1	09	04	H0097_002_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00
H0097	002	0	1	09	04	H0097_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H0097	002	0	1	09	04	H0097_002_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H0097	002	0	1	09	04	H0097_002_0	8	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0104	002	0	1	04	01	H0104_002_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H0104	002	0	1	04	01	H0104_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H0104	002	0	1	04	01	H0104_002_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H0104	002	0	1	04	01	H0104_002_0	8	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0104	004	0	1	04	01	H0104_004_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0104	004	0	1	04	01	H0104_004_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0104	004	0	1	04	01	H0104_004_0	7	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0104	004	0	1	04	01	H0104_004_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H0104	004	0	1	04	01	H0104_004_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0104	004	0	1	04	01	H0104_004_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H0104	004	0	1	04	01	H0104_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H0104	004	0	1	04	01	H0104_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H0104	006	0	1	04	01	H0104_006_0	5	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	1	Generic	25	25								25		25	25								25	Generic																					
H0104	006	0	1	04	01	H0104_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
H0104	006	0	1	04	01	H0104_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25		25	25								25	Non-Preferred Brand																					
H0104	006	0	1	04	01	H0104_006_0	5	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H0104	008	0	1	04	01	H0104_008_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0104	008	0	1	04	01	H0104_008_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H0104	008	0	1	04	01	H0104_008_0	6	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0104	008	0	1	04	01	H0104_008_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H0104	008	0	1	04	01	H0104_008_0	6	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0104	008	0	1	04	01	H0104_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H0104	008	0	1	04	01	H0104_008_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H0104	008	0	1	04	01	H0104_008_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0117	004	0	1	01	01	H0117_004_0	10	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0117	004	0	1	01	01	H0117_004_0	10	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0117	004	0	1	01	01	H0117_004_0	10	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0117	004	0	1	01	01	H0117_004_0	10	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	004	0	1	01	01	H0117_004_0	10	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H0117	004	0	1	01	01	H0117_004_0	10	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00
H0117	004	0	1	01	01	H0117_004_0	10	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0117	004	0	1	01	01	H0117_004_0	10	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	005	0	1	01	01	H0117_005_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0117	005	0	1	01	01	H0117_005_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0117	005	0	1	01	01	H0117_005_0	7	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0117	005	0	1	01	01	H0117_005_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	005	0	1	01	01	H0117_005_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	005	0	1	01	01	H0117_005_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0117	005	0	1	01	01	H0117_005_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H0117	005	0	1	01	01	H0117_005_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0117	007	0	1	01	01	H0117_007_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	007	0	1	01	01	H0117_007_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0117	007	0	1	01	01	H0117_007_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
H0117	007	0	1	01	01	H0117_007_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0117	008	0	1	01	01	H0117_008_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0117	008	0	1	01	01	H0117_008_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H0117	008	0	1	01	01	H0117_008_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0117	008	0	1	01	01	H0117_008_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	009	0	1	01	01	H0117_009_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0117	009	0	1	01	01	H0117_009_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00
H0117	009	0	1	01	01	H0117_009_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	91.00	273.00								91.00			273.00								91.00
H0117	009	0	1	01	01	H0117_009_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0141	001	0	1	01	01	H0141_001_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0141	001	0	1	01	01	H0141_001_0	6	4	4	1	Tier 4	100000	1	2				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	2	Tier 4																						Tier 4	81.00	243.00								81.00			243.00								81.00
H0141	001	0	1	01	01	H0141_001_0	6	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	1	Tier 3	25	25								25			25								25	Tier 3																					
H0141	001	0	1	01	01	H0141_001_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	40.50	121.50								40.50			121.50								40.50
H0150	001	0	1	01	01	H0150_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	001	0	1	01	01	H0150_001_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	001	0	1	01	01	H0150_001_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0150	001	0	1	01	01	H0150_001_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0150	001	0	1	01	01	H0150_001_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0150	001	0	1	01	01	H0150_001_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	001	0	1	01	01	H0150_001_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	001	0	1	01	01	H0150_001_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0150	001	0	1	01	01	H0150_001_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H0150	001	0	1	01	01	H0150_001_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H0150	017	0	1	01	01	H0150_017_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00			6.00								2.00
H0150	017	0	1	01	01	H0150_017_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0150	017	0	1	01	01	H0150_017_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0150	017	0	1	01	01	H0150_017_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	017	0	1	01	01	H0150_017_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0150	017	0	1	01	01	H0150_017_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0150	017	0	1	01	01	H0150_017_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H0150	017	0	1	01	01	H0150_017_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H0150	017	0	1	01	01	H0150_017_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	017	0	1	01	01	H0150_017_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00			6.00								2.00
H0150	019	0	1	01	01	H0150_019_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	019	0	1	01	01	H0150_019_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H0150	019	0	1	01	01	H0150_019_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0150	019	0	1	01	01	H0150_019_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0150	019	0	1	01	01	H0150_019_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0150	019	0	1	01	01	H0150_019_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H0150	019	0	1	01	01	H0150_019_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	019	0	1	01	01	H0150_019_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0150	019	0	1	01	01	H0150_019_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H0150	019	0	1	01	01	H0150_019_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H0150	021	0	1	01	01	H0150_021_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	021	0	1	01	01	H0150_021_0	4	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	021	0	1	01	01	H0150_021_0	4	3	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0150	021	0	1	01	01	H0150_021_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H0150	021	0	1	01	01	H0150_021_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0150	021	0	1	01	01	H0150_021_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0150	021	0	1	01	01	H0150_021_0	4	2	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00
H0150	021	0	1	01	01	H0150_021_0	4	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H0150	021	0	1	01	01	H0150_021_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0150	021	0	1	01	01	H0150_021_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0151	001	0	1	01	01	H0151_001_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H0151	001	0	1	01	01	H0151_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0151	001	0	1	01	01	H0151_001_0	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0151	001	0	1	01	01	H0151_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0151	017	0	1	01	01	H0151_017_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0151	017	0	1	01	01	H0151_017_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0151	017	0	1	01	01	H0151_017_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0151	017	0	1	01	01	H0151_017_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0151	023	0	1	01	01	H0151_023_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0151	023	0	1	01	01	H0151_023_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0151	023	0	1	01	01	H0151_023_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0151	023	0	1	01	01	H0151_023_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0151	023	0	1	01	01	H0151_023_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0151	023	0	1	01	01	H0151_023_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0151	023	0	1	01	01	H0151_023_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0151	023	0	1	01	01	H0151_023_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0154	001	0	1	01	01	H0154_001_0	5	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00			165.00								55.00
H0154	001	0	1	01	01	H0154_001_0	5	4	3	1	Tier 4	010010		1				Tier 4	110000000010000000000	31									31											31	Tier 4	2	1	Tier 4	27									27											27	Tier 4																					
H0154	001	0	1	01	01	H0154_001_0	5	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00
H0154	001	0	1	01	01	H0154_001_0	5	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
H0154	009	0	1	01	01	H0154_009_0	6	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00			165.00								55.00
H0154	009	0	1	01	01	H0154_009_0	6	4	3	1	Tier 4	010010		1				Tier 4	110000000010000000000	31									31											31	Tier 4	2	1	Tier 4	27									27											27	Tier 4																					
H0154	009	0	1	01	01	H0154_009_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
H0154	009	0	1	01	01	H0154_009_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00
H0154	011	0	1	01	01	H0154_011_0	4	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00
H0154	011	0	1	01	01	H0154_011_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0154	011	0	1	01	01	H0154_011_0	4	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0154	011	0	1	01	01	H0154_011_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
H0154	011	0	1	01	01	H0154_011_0	4	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00
H0154	011	0	1	01	01	H0154_011_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	31									31											31	Tier 4	2	1	Tier 4	33									33											33	Tier 4																					
H0154	011	0	1	01	01	H0154_011_0	4	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00			165.00								55.00
H0154	011	0	1	01	01	H0154_011_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0245	001	0	1	01	01	H0245_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H0245	001	0	1	01	01	H0245_001_0	7	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H0245	001	0	1	01	01	H0245_001_0	7	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0245	001	0	1	01	01	H0245_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H0245	002	0	1	01	01	H0245_002_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H0245	002	0	1	01	01	H0245_002_0	7	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H0245	002	0	1	01	01	H0245_002_0	7	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H0245	002	0	1	01	01	H0245_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H0245	002	0	1	01	01	H0245_002_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H0245	002	0	1	01	01	H0245_002_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0245	002	0	1	01	01	H0245_002_0	7	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0245	002	0	1	01	01	H0245_002_0	7	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0248	001	0	1	04	01	H0248_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0248	001	0	1	04	01	H0248_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0248	001	0	1	04	01	H0248_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H0248	001	0	1	04	01	H0248_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0248	001	0	1	04	01	H0248_001_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0248	001	0	1	04	01	H0248_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H0248	001	0	1	04	01	H0248_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0248	001	0	1	04	01	H0248_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0302	001	0	1	01	01	H0302_001_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0302	001	0	1	01	01	H0302_001_0	4	1	4	1	Value Generics	010000	1	2				Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	4.00	12.00								4.00		10.00	10.00								4.00
H0302	001	0	1	01	01	H0302_001_0	4	2	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	12.00	36.00								12.00		30.00	30.00								12.00
H0302	001	0	1	01	01	H0302_001_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H0302	001	0	1	01	01	H0302_001_0	4	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H0302	001	0	1	01	01	H0302_001_0	4	5	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H0302	001	0	1	01	01	H0302_001_0	4	1	4	3	Value Generics	010000	1	2	1		1	Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	8.00	24.00								8.00		20.00	20.00								8.00
H0302	001	0	1	01	01	H0302_001_0	4	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	24.00	72.00								24.00		60.00	60.00								24.00
H0302	001	0	1	01	01	H0302_001_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0302	001	0	1	01	01	H0302_001_0	4	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0302	004	0	1	01	01	H0302_004_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0302	004	0	1	01	01	H0302_004_0	4	1	4	1	Value Generics	010000	1	2				Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	4.00	12.00								4.00		10.00	10.00								4.00
H0302	004	0	1	01	01	H0302_004_0	4	2	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	12.00	36.00								12.00		30.00	30.00								12.00
H0302	004	0	1	01	01	H0302_004_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H0302	004	0	1	01	01	H0302_004_0	4	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0302	004	0	1	01	01	H0302_004_0	4	5	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H0302	004	0	1	01	01	H0302_004_0	4	1	4	3	Value Generics	010000	1	2	1		1	Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	8.00	24.00								8.00		20.00	20.00								8.00
H0302	004	0	1	01	01	H0302_004_0	4	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	24.00	72.00								24.00		60.00	60.00								24.00
H0302	004	0	1	01	01	H0302_004_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0302	004	0	1	01	01	H0302_004_0	4	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H0303	013	0	1	01	01	H0303_013_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0303	013	0	1	01	01	H0303_013_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0303	013	0	1	01	01	H0303_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0303	013	0	1	01	01	H0303_013_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0303	015	0	1	01	01	H0303_015_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0303	015	0	1	01	01	H0303_015_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0303	015	0	1	01	01	H0303_015_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0303	015	0	1	01	01	H0303_015_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0303	039	0	1	01	01	H0303_039_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0303	039	0	1	01	01	H0303_039_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0303	039	0	1	01	01	H0303_039_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0303	039	0	1	01	01	H0303_039_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0307	008	0	1	01	01	H0307_008_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	008	0	1	01	01	H0307_008_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0307	008	0	1	01	01	H0307_008_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H0307	008	0	1	01	01	H0307_008_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0307	008	0	1	01	01	H0307_008_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H0307	008	0	1	01	01	H0307_008_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0307	008	0	1	01	01	H0307_008_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0307	008	0	1	01	01	H0307_008_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	009	0	1	02	01	H0307_009_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0307	009	0	1	02	01	H0307_009_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0307	009	0	1	02	01	H0307_009_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H0307	009	0	1	02	01	H0307_009_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	009	0	1	02	01	H0307_009_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0307	009	0	1	02	01	H0307_009_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	009	0	1	02	01	H0307_009_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0307	009	0	1	02	01	H0307_009_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H0307	010	0	1	02	01	H0307_010_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0307	010	0	1	02	01	H0307_010_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H0307	010	0	1	02	01	H0307_010_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	010	0	1	02	01	H0307_010_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0307	010	0	1	02	01	H0307_010_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0307	010	0	1	02	01	H0307_010_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0307	010	0	1	02	01	H0307_010_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H0307	010	0	1	02	01	H0307_010_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H0316	002	0	1	01	01	H0316_002_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0316	002	0	1	01	01	H0316_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0316	002	0	1	01	01	H0316_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0316	002	0	1	01	01	H0316_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0316	013	0	1	01	01	H0316_013_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0316	013	0	1	01	01	H0316_013_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0316	013	0	1	01	01	H0316_013_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0316	013	0	1	01	01	H0316_013_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0316	014	0	1	01	01	H0316_014_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0316	014	0	1	01	01	H0316_014_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0316	014	0	1	01	01	H0316_014_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0316	014	0	1	01	01	H0316_014_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0317	001	0	1	04	01	H0317_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H0317	001	0	1	04	01	H0317_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	001	0	1	04	01	H0317_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0317	001	0	1	04	01	H0317_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0317	001	0	1	04	01	H0317_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H0317	001	0	1	04	01	H0317_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	001	0	1	04	01	H0317_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H0317	001	0	1	04	01	H0317_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0317	002	0	1	04	01	H0317_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	002	0	1	04	01	H0317_002_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0317	002	0	1	04	01	H0317_002_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0317	002	0	1	04	01	H0317_002_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0317	002	0	1	04	01	H0317_002_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	002	0	1	04	01	H0317_002_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0317	002	0	1	04	01	H0317_002_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0317	002	0	1	04	01	H0317_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0317	004	0	1	04	01	H0317_004_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0317	004	0	1	04	01	H0317_004_0	8	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H0317	004	0	1	04	01	H0317_004_0	8	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	004	0	1	04	01	H0317_004_0	8	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H0317	004	0	1	04	01	H0317_004_0	8	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0317	004	0	1	04	01	H0317_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H0317	004	0	1	04	01	H0317_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H0317	004	0	1	04	01	H0317_004_0	8	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0318	001	0	1	01	01	H0318_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0318	001	0	1	01	01	H0318_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0318	001	0	1	01	01	H0318_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0318	001	0	1	01	01	H0318_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0318	001	0	1	01	01	H0318_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H0318	002	0	1	01	01	H0318_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0318	002	0	1	01	01	H0318_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0318	002	0	1	01	01	H0318_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0318	002	0	1	01	01	H0318_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H0318	002	0	1	01	01	H0318_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0319	001	0	1	04	01	H0319_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0319	001	0	1	04	01	H0319_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0319	001	0	1	04	01	H0319_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0319	001	0	1	04	01	H0319_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0319	004	0	1	04	01	H0319_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0319	004	0	1	04	01	H0319_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0319	004	0	1	04	01	H0319_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0319	004	0	1	04	01	H0319_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0319	005	0	1	04	01	H0319_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0319	005	0	1	04	01	H0319_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0319	005	0	1	04	01	H0319_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0319	005	0	1	04	01	H0319_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0320	001	0	1	01	01	H0320_001_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H0320	001	0	1	01	01	H0320_001_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H0320	001	0	1	01	01	H0320_001_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H0320	001	0	1	01	01	H0320_001_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0320	001	0	1	01	01	H0320_001_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H0320	001	0	1	01	01	H0320_001_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H0320	001	0	1	01	01	H0320_001_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H0320	001	0	1	01	01	H0320_001_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0320	005	0	1	01	01	H0320_005_0	10	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0320	005	0	1	01	01	H0320_005_0	10	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H0320	005	0	1	01	01	H0320_005_0	10	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H0320	005	0	1	01	01	H0320_005_0	10	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H0320	005	0	1	01	01	H0320_005_0	10	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0320	005	0	1	01	01	H0320_005_0	10	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H0320	005	0	1	01	01	H0320_005_0	10	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H0320	005	0	1	01	01	H0320_005_0	10	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H0320	006	0	1	01	01	H0320_006_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H0320	006	0	1	01	01	H0320_006_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H0320	006	0	1	01	01	H0320_006_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H0320	006	0	1	01	01	H0320_006_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0320	006	0	1	01	01	H0320_006_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H0320	006	0	1	01	01	H0320_006_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H0320	006	0	1	01	01	H0320_006_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H0320	006	0	1	01	01	H0320_006_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0322	002	0	1	04	01	H0322_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H0322	002	0	1	04	01	H0322_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0322	002	0	1	04	01	H0322_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0322	002	0	1	04	01	H0322_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0322	002	0	1	04	01	H0322_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0322	006	0	1	04	01	H0322_006_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0322	006	0	1	04	01	H0322_006_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0322	006	0	1	04	01	H0322_006_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0322	006	0	1	04	01	H0322_006_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0322	006	0	1	04	01	H0322_006_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H0322	006	0	1	04	01	H0322_006_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H0322	006	0	1	04	01	H0322_006_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0322	006	0	1	04	01	H0322_006_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0322	006	0	1	04	01	H0322_006_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H0322	006	0	1	04	01	H0322_006_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0332	002	0	1	01	01	H0332_002_0	9	4	4	1	Specialty	000010	1	1				Specialty	100011011010110000000				30	90		30	90		30		30								90	31	Specialty	2	1	Specialty				30	30		30	30		30		30	30								30	Specialty																					
H0332	002	0	1	01	01	H0332_002_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	150.00		60.00	180.00		60.00		50.00	150.00								60.00
H0332	002	0	1	01	01	H0332_002_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0332	002	0	1	01	01	H0332_002_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0332	002	0	1	01	01	H0332_002_0	9	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0332	002	0	1	01	01	H0332_002_0	9	1	4	3	Generic	010000	3	2	1		1	Generic	100011011010110000000				30	90		30	90		30		30								90	31	Generic	2	2	Generic																						Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
H0332	002	0	1	01	01	H0332_002_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				20.00	60.00		30.00	90.00		30.00		20.00	60.00								30.00
H0332	002	0	1	01	01	H0332_002_0	9	1	4	1	Generic	010000	3	2				Generic	100011011010110000000				30	90		30	90		30		30								90	31	Generic	2	2	Generic																						Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
H0332	004	0	1	02	01	H0332_004_0	9	4	4	1	Specialty	000010	1	1				Specialty	100011011010110000000				30	90		30	90		30		30								90	31	Specialty	2	1	Specialty				30	30		30	30		30		30	30								30	Specialty																					
H0332	004	0	1	02	01	H0332_004_0	9	1	4	3	Generic	010000	3	2	1		1	Generic	100011011010110000000				30	90		30	90		30		30								90	31	Generic	2	2	Generic																						Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
H0332	004	0	1	02	01	H0332_004_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0332	004	0	1	02	01	H0332_004_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0332	004	0	1	02	01	H0332_004_0	9	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0332	004	0	1	02	01	H0332_004_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	150.00		60.00	180.00		60.00		50.00	150.00								60.00
H0332	004	0	1	02	01	H0332_004_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				20.00	60.00		30.00	90.00		30.00		20.00	60.00								30.00
H0332	004	0	1	02	01	H0332_004_0	9	1	4	1	Generic	010000	3	2				Generic	100011011010110000000				30	90		30	90		30		30								90	31	Generic	2	2	Generic																						Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
H0351	014	0	1	01	01	H0351_014_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H0351	014	0	1	01	01	H0351_014_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0351	014	0	1	01	01	H0351_014_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0351	014	0	1	01	01	H0351_014_0	4	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0351	014	0	1	01	01	H0351_014_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0351	029	0	1	01	01	H0351_029_0	6	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
H0351	029	0	1	01	01	H0351_029_0	6	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						150.00	150.00	75.00	225.00	150.00	75.00
H0351	029	0	1	01	01	H0351_029_0	6	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
H0351	029	0	1	01	01	H0351_029_0	6	5	2	1	Speciality	010010		1				Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	25									25					25			25			25	Speciality																					
H0351	029	0	1	01	01	H0351_029_0	6	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00	56.00							28.00						56.00	56.00	28.00	84.00	56.00	28.00
H0351	032	0	1	01	01	H0351_032_0	6	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0351	032	0	1	01	01	H0351_032_0	6	4	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0351	032	0	1	01	01	H0351_032_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0351	032	0	1	01	01	H0351_032_0	6	2	4	3	Preferred Generic	001000	1	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H0351	032	0	1	01	01	H0351_032_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0351	032	0	1	01	01	H0351_032_0	6	6	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0351	032	0	1	01	01	H0351_032_0	6	5	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0351	032	0	1	01	01	H0351_032_0	6	4	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0351	032	0	1	01	01	H0351_032_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0351	032	0	1	01	01	H0351_032_0	6	2	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H0351	032	0	1	01	01	H0351_032_0	6	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0351	032	0	1	01	01	H0351_032_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0351	033	0	1	01	01	H0351_033_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	86.00	258.00	172.00							86.00						215.00	215.00	86.00	258.00	172.00	86.00
H0351	033	0	1	01	01	H0351_033_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
H0351	033	0	1	01	01	H0351_033_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H0351	033	0	1	01	01	H0351_033_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0351	033	0	1	01	01	H0351_033_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0351	034	0	1	01	01	H0351_034_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00	6.00							3.00						6.00	6.00	3.00	9.00	6.00	3.00
H0351	034	0	1	01	01	H0351_034_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
H0351	034	0	1	01	01	H0351_034_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
H0351	034	0	1	01	01	H0351_034_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0351	034	0	1	01	01	H0351_034_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0354	001	0	1	01	01	H0354_001_0	11	4	4	1	Tier 4	110000	1	2				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	165.00								55.00
H0354	001	0	1	01	01	H0354_001_0	11	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H0354	001	0	1	01	01	H0354_001_0	11	4	4	3	Tier 4	110000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0354	001	0	1	01	01	H0354_001_0	11	3	4	3	Tier 3	010001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0354	001	0	1	01	01	H0354_001_0	11	2	4	3	Tier 2	010010	1	2	1		1	Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	5.00	15.00								5.00		5.00	15.00								5.00
H0354	001	0	1	01	01	H0354_001_0	11	1	4	3	Tier 1	010010	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H0354	001	0	1	01	01	H0354_001_0	11	5	4	1	Tier 5	010010	1	1				Tier 5	111000000010110000000	30	90								30		30								90	31	Tier 5	2	2	Tier 5																						Tier 5	55.00	165.00								55.00		55.00	165.00								55.00
H0354	001	0	1	01	01	H0354_001_0	11	3	4	1	Tier 3	010001	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	105.00								35.00
H0354	001	0	1	01	01	H0354_001_0	11	2	4	1	Tier 2	010010	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	5.00	15.00								5.00		5.00	15.00								5.00
H0354	001	0	1	01	01	H0354_001_0	11	1	4	1	Tier 1	010010	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H0354	014	0	1	01	01	H0354_014_0	11	1	4	1	Tier 1	010010	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H0354	014	0	1	01	01	H0354_014_0	11	5	4	1	Tier 5	010010	1	1				Tier 5	111000000010110000000	30	90								30		30								90	31	Tier 5	2	2	Tier 5																						Tier 5	55.00	165.00								55.00		55.00	165.00								55.00
H0354	014	0	1	01	01	H0354_014_0	11	1	4	3	Tier 1	010010	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H0354	014	0	1	01	01	H0354_014_0	11	4	4	1	Tier 4	110000	1	2				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	165.00								55.00
H0354	014	0	1	01	01	H0354_014_0	11	2	4	3	Tier 2	010010	1	2	1		1	Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	5.00	15.00								5.00		5.00	15.00								5.00
H0354	014	0	1	01	01	H0354_014_0	11	2	4	1	Tier 2	010010	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	5.00	15.00								5.00		5.00	15.00								5.00
H0354	014	0	1	01	01	H0354_014_0	11	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H0354	014	0	1	01	01	H0354_014_0	11	4	4	3	Tier 4	110000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0354	014	0	1	01	01	H0354_014_0	11	3	4	3	Tier 3	010001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0354	014	0	1	01	01	H0354_014_0	11	3	4	1	Tier 3	010001	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	105.00								35.00
H0370	001	0	1	04	01	H0370_001_0	11	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H0370	001	0	1	04	01	H0370_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H0370	001	0	1	04	01	H0370_001_0	11	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0370	001	0	1	04	01	H0370_001_0	11	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H0370	001	0	1	04	01	H0370_001_0	11	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H0370	001	0	1	04	01	H0370_001_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0370	001	0	1	04	01	H0370_001_0	11	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0370	001	0	1	04	01	H0370_001_0	11	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H0370	002	0	1	04	01	H0370_002_0	12	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H0370	002	0	1	04	01	H0370_002_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H0370	002	0	1	04	01	H0370_002_0	12	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0370	002	0	1	04	01	H0370_002_0	12	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H0370	002	0	1	04	01	H0370_002_0	12	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H0370	002	0	1	04	01	H0370_002_0	12	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H0370	002	0	1	04	01	H0370_002_0	12	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H0370	002	0	1	04	01	H0370_002_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0401	002	0	1	02	01	H0401_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0401	002	0	1	02	01	H0401_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0401	002	0	1	02	01	H0401_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0401	002	0	1	02	01	H0401_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						0.00			12.00		4.00
H0401	005	0	1	02	01	H0401_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0401	005	0	1	02	01	H0401_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0401	005	0	1	02	01	H0401_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0401	005	0	1	02	01	H0401_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0408	001	0	1	02	01	H0408_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0408	001	0	1	02	01	H0408_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0408	001	0	1	02	01	H0408_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0408	001	0	1	02	01	H0408_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0408	002	0	1	02	01	H0408_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0408	002	0	1	02	01	H0408_002_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0408	002	0	1	02	01	H0408_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0408	002	0	1	02	01	H0408_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0410	001	0	1	37	05	H0410_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0410	001	0	1	37	05	H0410_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0410	001	0	1	37	05	H0410_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0410	001	0	1	37	05	H0410_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H0410	003	0	1	37	05	H0410_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0410	003	0	1	37	05	H0410_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0410	003	0	1	37	05	H0410_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0410	003	0	1	37	05	H0410_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H0410	004	0	1	37	05	H0410_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0410	004	0	1	37	05	H0410_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0410	004	0	1	37	05	H0410_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0410	004	0	1	37	05	H0410_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H0427	001	0	1	02	01	H0427_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H0427	001	0	1	02	01	H0427_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	110.00								55.00			110.00								55.00
H0427	001	0	1	02	01	H0427_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H0427	001	0	1	02	01	H0427_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H0427	002	0	1	02	01	H0427_002_0	7	2	3	1	Brand	000010		2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	56.00								28.00			56.00								28.00
H0427	002	0	1	02	01	H0427_002_0	7	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00
H0427	002	0	1	02	01	H0427_002_0	7	3	3	1	Specialty	010010		1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H0490	001	0	1	01	01	H0490_001_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0490	001	0	1	01	01	H0490_001_0	6	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H0490	001	0	1	01	01	H0490_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H0490	001	0	1	01	01	H0490_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H0490	002	0	1	01	01	H0490_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			15.00								0.00
H0490	002	0	1	01	01	H0490_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			60.00								20.00
H0490	002	0	1	01	01	H0490_002_0	6	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H0490	002	0	1	01	01	H0490_002_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0490	003	0	1	01	01	H0490_003_0	6	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H0490	003	0	1	01	01	H0490_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H0490	003	0	1	01	01	H0490_003_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H0490	003	0	1	01	01	H0490_003_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H0504	015	0	1	01	01	H0504_015_0	9	4	4	1	Injectables	001001	1	2				Injectables	100011011010010000000				30	90		30	90		30										90	34	Injectables	2	1	Injectables				33	33		33	33		33			33								33	Injectables																					
H0504	015	0	1	01	01	H0504_015_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				60.00	120.00		60.00	180.00		60.00			120.00								60.00
H0504	015	0	1	01	01	H0504_015_0	9	2	4	1	Formulary Brand	000001	1	2				Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H0504	015	0	1	01	01	H0504_015_0	9	1	4	1	Formulary Generic	001000	3	2				Formulary Generic	100011011010010000000				30	90		30	90		30										90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic				6.00	12.00		6.00	18.00		6.00			12.00								6.00
H0504	015	0	1	01	01	H0504_015_0	9	5	4	3	Formulary Specialty (Unique High Cost Drugs)	001001	1	1	2			Formulary Specialty (Unique High Cost Drugs)																							Formulary Specialty (Unique High Cost Drugs)			Formulary Specialty (Unique High Cost Drugs)																						Formulary Specialty (Unique High Cost Drugs)																					
H0504	015	0	1	01	01	H0504_015_0	9	1	4	3	Formulary Generic	001000	3	2	1		1	Formulary Generic	100011011010010000000				30	90		30	90		30										90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic				6.00	12.00		6.00	18.00		6.00			12.00								6.00
H0504	015	0	1	01	01	H0504_015_0	9	2	4	3	Formulary Brand	000001	1	2	1		1	Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	1	Formulary Brand				50	50		55	55		50			50								50	Formulary Brand																					
H0504	015	0	1	01	01	H0504_015_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0504	015	0	1	01	01	H0504_015_0	9	4	4	3	Injectables	001001	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0504	015	0	1	01	01	H0504_015_0	9	5	4	1	Formulary Specialty (Unique High Cost Drugs)	001001	1	1				Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30										90	34	Formulary Specialty (Unique High Cost Drugs)	2	1	Formulary Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary Specialty (Unique High Cost Drugs)																					
H0504	017	0	1	01	01	H0504_017_0	8	4	4	1	Injectables	001001	1	2				Injectables	100011011010010000000				30	90		30	90		30										90	34	Injectables	2	1	Injectables				33	33		33	33		33			33								33	Injectables																					
H0504	017	0	1	01	01	H0504_017_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				60.00	120.00		60.00	180.00		60.00			120.00								60.00
H0504	017	0	1	01	01	H0504_017_0	8	2	4	1	Formulary Brand	000001	1	2				Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H0504	017	0	1	01	01	H0504_017_0	8	1	4	1	Formulary Generic	001000	3	2				Formulary Generic	100011011010010000000				30	90		30	90		30										90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00
H0504	017	0	1	01	01	H0504_017_0	8	5	4	1	Formulary Specialty (Unique High Cost Drugs)	001001	1	1				Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30										90	34	Formulary Specialty (Unique High Cost Drugs)	2	1	Formulary Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary Specialty (Unique High Cost Drugs)																					
H0504	017	0	1	01	01	H0504_017_0	8	5	4	3	Formulary Specialty (Unique High Cost Drugs)	001001	1	1	2			Formulary Specialty (Unique High Cost Drugs)																							Formulary Specialty (Unique High Cost Drugs)			Formulary Specialty (Unique High Cost Drugs)																						Formulary Specialty (Unique High Cost Drugs)																					
H0504	017	0	1	01	01	H0504_017_0	8	4	4	3	Injectables	001001	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0504	017	0	1	01	01	H0504_017_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0504	017	0	1	01	01	H0504_017_0	8	2	4	3	Formulary Brand	000001	1	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H0504	017	0	1	01	01	H0504_017_0	8	1	4	3	Formulary Generic	001000	3	2	1		1	Formulary Generic	100011011010010000000				30	90		30	90		30										90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00
H0504	021	0	1	01	01	H0504_021_0	8	1	4	1	Formulary Insulin and Generics	001001	3	2				Formulary Insulin and Generics	100011011010010000000				30	90		30	90		30										90	34	Formulary Insulin and Generics	2	2	Formulary Insulin and Generics																						Formulary Insulin and Generics				0.00	0.00		0.00	0.00		0.00			0.00								0.00
H0504	021	0	1	01	01	H0504_021_0	8	2	4	1	Formulary Brand	000001	1	2				Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				15.00	30.00		15.00	45.00		15.00			30.00								15.00
H0504	021	0	1	01	01	H0504_021_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				60.00	120.00		60.00	180.00		60.00			120.00								60.00
H0504	021	0	1	01	01	H0504_021_0	8	4	4	1	Injectables	001001	1	2				Injectables	100011011010010000000				30	90		30	90		30										90	34	Injectables	2	1	Injectables				33	33		33	33		33			33								33	Injectables																					
H0504	021	0	1	01	01	H0504_021_0	8	5	4	3	Formulary  Specialty (Unique High Cost Drugs)	001001	1	1	2			Formulary  Specialty (Unique High Cost Drugs)																							Formulary  Specialty (Unique High Cost Drugs)			Formulary  Specialty (Unique High Cost Drugs)																						Formulary  Specialty (Unique High Cost Drugs)																					
H0504	021	0	1	01	01	H0504_021_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0504	021	0	1	01	01	H0504_021_0	8	2	4	3	Formulary Brand	000001	1	2	1		1	Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				15.00	30.00		15.00	45.00		15.00			30.00								15.00
H0504	021	0	1	01	01	H0504_021_0	8	1	4	3	Formulary Insulin and Generics	001001	3	2	1		1	Formulary Insulin and Generics	100011011010010000000				30	90		30	90		30										90	34	Formulary Insulin and Generics	2	2	Formulary Insulin and Generics																						Formulary Insulin and Generics				0.00	0.00		0.00	0.00		0.00			0.00								0.00
H0504	021	0	1	01	01	H0504_021_0	8	5	4	1	Formulary  Specialty (Unique High Cost Drugs)	001001	1	1				Formulary  Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30										90	34	Formulary  Specialty (Unique High Cost Drugs)	2	1	Formulary  Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary  Specialty (Unique High Cost Drugs)																					
H0504	021	0	1	01	01	H0504_021_0	8	4	4	3	Injectables	001001	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0523	002	0	1	01	01	H0523_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	002	0	1	01	01	H0523_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0523	002	0	1	01	01	H0523_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0523	002	0	1	01	01	H0523_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	94.00	282.00									94.00					188.00			282.00		94.00
H0523	002	0	1	01	01	H0523_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	022	0	1	01	01	H0523_022_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	022	0	1	01	01	H0523_022_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	94.00	282.00									94.00					188.00			282.00		94.00
H0523	022	0	1	01	01	H0523_022_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	022	0	1	01	01	H0523_022_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0523	022	0	1	01	01	H0523_022_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0523	031	0	1	01	01	H0523_031_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	031	0	1	01	01	H0523_031_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H0523	031	0	1	01	01	H0523_031_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0523	031	0	1	01	01	H0523_031_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0523	031	0	1	01	01	H0523_031_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	032	0	1	01	01	H0523_032_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	032	0	1	01	01	H0523_032_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H0523	032	0	1	01	01	H0523_032_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	032	0	1	01	01	H0523_032_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H0523	032	0	1	01	01	H0523_032_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H0523	034	0	1	01	01	H0523_034_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H0523	034	0	1	01	01	H0523_034_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	034	0	1	01	01	H0523_034_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0523	034	0	1	01	01	H0523_034_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0523	034	0	1	01	01	H0523_034_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0523	034	0	1	01	01	H0523_034_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	034	0	1	01	01	H0523_034_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	034	0	1	01	01	H0523_034_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H0523	034	0	1	01	01	H0523_034_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H0523	034	0	1	01	01	H0523_034_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	047	0	1	01	01	H0523_047_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H0523	047	0	1	01	01	H0523_047_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	047	0	1	01	01	H0523_047_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0523	047	0	1	01	01	H0523_047_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0523	047	0	1	01	01	H0523_047_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0523	047	0	1	01	01	H0523_047_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	047	0	1	01	01	H0523_047_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H0523	047	0	1	01	01	H0523_047_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H0523	047	0	1	01	01	H0523_047_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	047	0	1	01	01	H0523_047_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	048	0	1	01	01	H0523_048_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H0523	048	0	1	01	01	H0523_048_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	048	0	1	01	01	H0523_048_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0523	048	0	1	01	01	H0523_048_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0523	048	0	1	01	01	H0523_048_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0523	048	0	1	01	01	H0523_048_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	048	0	1	01	01	H0523_048_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H0523	048	0	1	01	01	H0523_048_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H0523	048	0	1	01	01	H0523_048_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	048	0	1	01	01	H0523_048_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	051	0	1	01	01	H0523_051_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H0523	051	0	1	01	01	H0523_051_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0523	051	0	1	01	01	H0523_051_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0523	051	0	1	01	01	H0523_051_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0523	051	0	1	01	01	H0523_051_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H0523	051	0	1	01	01	H0523_051_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H0523	051	0	1	01	01	H0523_051_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H0523	051	0	1	01	01	H0523_051_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H0523	051	0	1	01	01	H0523_051_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0523	051	0	1	01	01	H0523_051_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H0524	002	0	2	01	01	H0524_002_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	002	0	2	01	01	H0524_002_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	002	0	2	01	01	H0524_002_0	6	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	8.00		24.00							8.00		8.00		16.00							8.00
H0524	002	0	2	01	01	H0524_002_0	6	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00
H0524	002	0	2	01	01	H0524_002_0	6	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	002	0	2	01	01	H0524_002_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	8.00		24.00							8.00		8.00		16.00							8.00
H0524	003	0	1	01	01	H0524_003_0	7	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	003	0	1	01	01	H0524_003_0	7	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00
H0524	003	0	1	01	01	H0524_003_0	7	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	003	0	1	01	01	H0524_003_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00
H0524	003	0	1	01	01	H0524_003_0	7	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	003	0	1	01	01	H0524_003_0	7	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	008	0	1	01	01	H0524_008_0	9	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	008	0	1	01	01	H0524_008_0	9	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	008	0	1	01	01	H0524_008_0	9	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	008	0	1	01	01	H0524_008_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	008	0	1	01	01	H0524_008_0	9	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	008	0	1	01	01	H0524_008_0	9	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	010	0	2	01	01	H0524_010_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	010	0	2	01	01	H0524_010_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	010	0	2	01	01	H0524_010_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	010	0	2	01	01	H0524_010_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	010	0	2	01	01	H0524_010_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	010	0	2	01	01	H0524_010_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	013	0	1	01	01	H0524_013_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	013	0	1	01	01	H0524_013_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	013	0	1	01	01	H0524_013_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	013	0	1	01	01	H0524_013_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	013	0	1	01	01	H0524_013_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	013	0	1	01	01	H0524_013_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	015	0	1	01	01	H0524_015_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	015	0	1	01	01	H0524_015_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00
H0524	015	0	1	01	01	H0524_015_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	015	0	1	01	01	H0524_015_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	015	0	1	01	01	H0524_015_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	015	0	1	01	01	H0524_015_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	029	0	1	01	01	H0524_029_0	5	1	3	1	Generic	010000		2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	8.00		24.00							8.00		8.00		16.00							8.00
H0524	029	0	1	01	01	H0524_029_0	5	2	3	1	Brand	000010		2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	48.00		144.00							48.00		48.00		96.00							48.00
H0524	029	0	1	01	01	H0524_029_0	5	3	3	1	Specialty	000010		1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	030	0	1	01	01	H0524_030_0	5	1	3	1	Generic	010000		2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	9.00		27.00							9.00		9.00		18.00							9.00
H0524	030	0	1	01	01	H0524_030_0	5	3	3	1	Specialty	000010		1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	030	0	1	01	01	H0524_030_0	5	2	3	1	Brand	000010		2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	48.00		144.00							48.00		48.00		96.00							48.00
H0524	031	0	1	01	01	H0524_031_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	031	0	1	01	01	H0524_031_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	031	0	1	01	01	H0524_031_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	031	0	1	01	01	H0524_031_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	031	0	1	01	01	H0524_031_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	031	0	1	01	01	H0524_031_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	032	0	1	01	01	H0524_032_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	032	0	1	01	01	H0524_032_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	032	0	1	01	01	H0524_032_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	032	0	1	01	01	H0524_032_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	032	0	1	01	01	H0524_032_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	032	0	1	01	01	H0524_032_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	033	0	1	01	01	H0524_033_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	033	0	1	01	01	H0524_033_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	033	0	1	01	01	H0524_033_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	033	0	1	01	01	H0524_033_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	033	0	1	01	01	H0524_033_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	033	0	1	01	01	H0524_033_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	034	0	1	01	01	H0524_034_0	6	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00
H0524	034	0	1	01	01	H0524_034_0	6	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00
H0524	034	0	1	01	01	H0524_034_0	6	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	034	0	1	01	01	H0524_034_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00
H0524	034	0	1	01	01	H0524_034_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	034	0	1	01	01	H0524_034_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0524	035	0	1	01	01	H0524_035_0	5	1	4	1	Generic	010000	1	2				Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	035	0	1	01	01	H0524_035_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H0524	035	0	1	01	01	H0524_035_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	110100000010101000000	30		100							30		30	100								31	Generic	2	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00
H0524	035	0	1	01	01	H0524_035_0	5	3	4	1	Specialty	000010	1	1				Specialty	110100000010101000000	30		100							30		30	100								31	Specialty	2	1	Specialty	25		25							25		25		25							25	Specialty																					
H0524	035	0	1	01	01	H0524_035_0	5	2	4	1	Brand	000010	1	2				Brand	110100000010101000000	30		100							30		30	100								31	Brand	2	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00
H0524	035	0	1	01	01	H0524_035_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0532	001	0	1	01	01	H0532_001_0	8	3	4	3	Tier 3 Non-Preferred Brand Drugs	100000	1	2	2			Tier 3 Non-Preferred Brand Drugs																							Tier 3 Non-Preferred Brand Drugs			Tier 3 Non-Preferred Brand Drugs																						Tier 3 Non-Preferred Brand Drugs																					
H0532	001	0	1	01	01	H0532_001_0	8	4	4	3	Tier 4 Specialty Drugs	000010	1	1	2			Tier 4 Specialty Drugs																							Tier 4 Specialty Drugs			Tier 4 Specialty Drugs																						Tier 4 Specialty Drugs																					
H0532	001	0	1	01	01	H0532_001_0	8	1	4	1	Tier 1 Generic Drugs	010000	1	2				Tier 1 Generic Drugs	111000000010010000000	34	90								34										90	34	Tier 1 Generic Drugs	1	2	Tier 1 Generic Drugs																						Tier 1 Generic Drugs	10.00	30.00								10.00			20.00								10.00
H0532	001	0	1	01	01	H0532_001_0	8	2	4	3	Tier 2 Preferred Brand Drugs	000001	1	2	2			Tier 2 Preferred Brand Drugs																							Tier 2 Preferred Brand Drugs			Tier 2 Preferred Brand Drugs																						Tier 2 Preferred Brand Drugs																					
H0532	001	0	1	01	01	H0532_001_0	8	3	4	1	Tier 3 Non-Preferred Brand Drugs	100000	1	2				Tier 3 Non-Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Tier 3 Non-Preferred Brand Drugs	1	2	Tier 3 Non-Preferred Brand Drugs																						Tier 3 Non-Preferred Brand Drugs	65.00	195.00								65.00			195.00								65.00
H0532	001	0	1	01	01	H0532_001_0	8	4	4	1	Tier 4 Specialty Drugs	000010	1	1				Tier 4 Specialty Drugs	111000000010010000000	34	90								34										90	34	Tier 4 Specialty Drugs	2	1	Tier 4 Specialty Drugs	33	33								33			33								33	Tier 4 Specialty Drugs																					
H0532	001	0	1	01	01	H0532_001_0	8	1	4	3	Tier 1 Generic Drugs	010000	1	2	1		1	Tier 1 Generic Drugs	111000000010010000000	34	90								34										90	34	Tier 1 Generic Drugs	1	2	Tier 1 Generic Drugs																						Tier 1 Generic Drugs	15.00	45.00								15.00			30.00								15.00
H0532	001	0	1	01	01	H0532_001_0	8	2	4	1	Tier 2 Preferred Brand Drugs	000001	1	2				Tier 2 Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Tier 2 Preferred Brand Drugs	1	2	Tier 2 Preferred Brand Drugs																						Tier 2 Preferred Brand Drugs	39.00	117.00								39.00			78.00								39.00
H0540	020	0	1	09	04	H0540_020_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	020	0	1	09	04	H0540_020_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H0540	020	0	1	09	04	H0540_020_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H0540	020	0	1	09	04	H0540_020_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H0540	020	0	1	09	04	H0540_020_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H0540	020	0	1	09	04	H0540_020_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	020	0	1	09	04	H0540_020_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H0540	020	0	1	09	04	H0540_020_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H0540	020	0	1	09	04	H0540_020_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H0540	020	0	1	09	04	H0540_020_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H0540	089	0	1	09	04	H0540_089_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H0540	089	0	1	09	04	H0540_089_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H0540	089	0	1	09	04	H0540_089_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H0540	089	0	1	09	04	H0540_089_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H0540	089	0	1	09	04	H0540_089_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H0540	089	0	1	09	04	H0540_089_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H0540	089	0	1	09	04	H0540_089_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	089	0	1	09	04	H0540_089_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H0540	089	0	1	09	04	H0540_089_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H0540	089	0	1	09	04	H0540_089_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	091	0	1	09	04	H0540_091_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	091	0	1	09	04	H0540_091_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H0540	091	0	1	09	04	H0540_091_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H0540	091	0	1	09	04	H0540_091_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H0540	091	0	1	09	04	H0540_091_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H0540	091	0	1	09	04	H0540_091_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0540	091	0	1	09	04	H0540_091_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H0540	091	0	1	09	04	H0540_091_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H0540	091	0	1	09	04	H0540_091_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H0540	091	0	1	09	04	H0540_091_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H0543	001	0	1	01	01	H0543_001_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	001	0	1	01	01	H0543_001_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	001	0	1	01	01	H0543_001_0	8	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	001	0	1	01	01	H0543_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	004	0	1	01	01	H0543_004_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	004	0	1	01	01	H0543_004_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	004	0	1	01	01	H0543_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	004	0	1	01	01	H0543_004_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	007	0	1	01	01	H0543_007_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	007	0	1	01	01	H0543_007_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	007	0	1	01	01	H0543_007_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	007	0	1	01	01	H0543_007_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	013	0	1	01	01	H0543_013_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	013	0	1	01	01	H0543_013_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	013	0	1	01	01	H0543_013_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	013	0	1	01	01	H0543_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	013	0	1	01	01	H0543_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	013	0	1	01	01	H0543_013_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	013	0	1	01	01	H0543_013_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	013	0	1	01	01	H0543_013_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	019	0	1	01	01	H0543_019_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	019	0	1	01	01	H0543_019_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	019	0	1	01	01	H0543_019_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	019	0	1	01	01	H0543_019_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	022	0	1	01	01	H0543_022_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	022	0	1	01	01	H0543_022_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	022	0	1	01	01	H0543_022_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	022	0	1	01	01	H0543_022_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	028	0	1	01	01	H0543_028_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	028	0	1	01	01	H0543_028_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	028	0	1	01	01	H0543_028_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	028	0	1	01	01	H0543_028_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	029	0	1	01	01	H0543_029_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	029	0	1	01	01	H0543_029_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	029	0	1	01	01	H0543_029_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	029	0	1	01	01	H0543_029_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	032	0	1	01	01	H0543_032_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	032	0	1	01	01	H0543_032_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	032	0	1	01	01	H0543_032_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	032	0	1	01	01	H0543_032_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	035	0	1	01	01	H0543_035_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	035	0	1	01	01	H0543_035_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	035	0	1	01	01	H0543_035_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	035	0	1	01	01	H0543_035_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	035	0	1	01	01	H0543_035_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	035	0	1	01	01	H0543_035_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	035	0	1	01	01	H0543_035_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	035	0	1	01	01	H0543_035_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	036	0	1	01	01	H0543_036_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	036	0	1	01	01	H0543_036_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	036	0	1	01	01	H0543_036_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	036	0	1	01	01	H0543_036_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	046	0	1	01	01	H0543_046_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	046	0	1	01	01	H0543_046_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	046	0	1	01	01	H0543_046_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	046	0	1	01	01	H0543_046_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	049	0	1	01	01	H0543_049_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	049	0	1	01	01	H0543_049_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	049	0	1	01	01	H0543_049_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	049	0	1	01	01	H0543_049_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	060	0	1	01	01	H0543_060_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	060	0	1	01	01	H0543_060_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	060	0	1	01	01	H0543_060_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	060	0	1	01	01	H0543_060_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	065	0	1	01	01	H0543_065_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	065	0	1	01	01	H0543_065_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	065	0	1	01	01	H0543_065_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	065	0	1	01	01	H0543_065_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	070	0	1	01	01	H0543_070_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	070	0	1	01	01	H0543_070_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	070	0	1	01	01	H0543_070_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	070	0	1	01	01	H0543_070_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	072	0	1	01	01	H0543_072_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	072	0	1	01	01	H0543_072_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	072	0	1	01	01	H0543_072_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	072	0	1	01	01	H0543_072_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	077	0	1	01	01	H0543_077_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	077	0	1	01	01	H0543_077_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	077	0	1	01	01	H0543_077_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	077	0	1	01	01	H0543_077_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	077	0	1	01	01	H0543_077_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	077	0	1	01	01	H0543_077_0	6	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	077	0	1	01	01	H0543_077_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	077	0	1	01	01	H0543_077_0	6	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0543	082	0	1	01	01	H0543_082_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	082	0	1	01	01	H0543_082_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	082	0	1	01	01	H0543_082_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	082	0	1	01	01	H0543_082_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	083	0	1	01	01	H0543_083_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	083	0	1	01	01	H0543_083_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	083	0	1	01	01	H0543_083_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	083	0	1	01	01	H0543_083_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	083	0	1	01	01	H0543_083_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	083	0	1	01	01	H0543_083_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	083	0	1	01	01	H0543_083_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	083	0	1	01	01	H0543_083_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	084	0	1	01	01	H0543_084_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	084	0	1	01	01	H0543_084_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	084	0	1	01	01	H0543_084_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	084	0	1	01	01	H0543_084_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	085	0	1	01	01	H0543_085_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	085	0	1	01	01	H0543_085_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	085	0	1	01	01	H0543_085_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	085	0	1	01	01	H0543_085_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	086	0	1	01	01	H0543_086_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	086	0	1	01	01	H0543_086_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	086	0	1	01	01	H0543_086_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	086	0	1	01	01	H0543_086_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	089	0	1	01	01	H0543_089_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	089	0	1	01	01	H0543_089_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	089	0	1	01	01	H0543_089_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	089	0	1	01	01	H0543_089_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	091	0	1	01	01	H0543_091_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	091	0	1	01	01	H0543_091_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	091	0	1	01	01	H0543_091_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	091	0	1	01	01	H0543_091_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	093	0	1	01	01	H0543_093_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	093	0	1	01	01	H0543_093_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	093	0	1	01	01	H0543_093_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	093	0	1	01	01	H0543_093_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	095	0	1	01	01	H0543_095_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	095	0	1	01	01	H0543_095_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	095	0	1	01	01	H0543_095_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	095	0	1	01	01	H0543_095_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	095	0	1	01	01	H0543_095_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	095	0	1	01	01	H0543_095_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	095	0	1	01	01	H0543_095_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	095	0	1	01	01	H0543_095_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	122	0	1	01	01	H0543_122_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	122	0	1	01	01	H0543_122_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	122	0	1	01	01	H0543_122_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	122	0	1	01	01	H0543_122_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H0543	122	0	1	01	01	H0543_122_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	122	0	1	01	01	H0543_122_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	122	0	1	01	01	H0543_122_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	122	0	1	01	01	H0543_122_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	125	0	1	01	01	H0543_125_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	125	0	1	01	01	H0543_125_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	125	0	1	01	01	H0543_125_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	125	0	1	01	01	H0543_125_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	126	0	1	01	01	H0543_126_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	126	0	1	01	01	H0543_126_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	126	0	1	01	01	H0543_126_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	126	0	1	01	01	H0543_126_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	127	0	1	01	01	H0543_127_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	127	0	1	01	01	H0543_127_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	127	0	1	01	01	H0543_127_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	127	0	1	01	01	H0543_127_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	127	0	1	01	01	H0543_127_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	127	0	1	01	01	H0543_127_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	127	0	1	01	01	H0543_127_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	127	0	1	01	01	H0543_127_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	128	0	1	01	01	H0543_128_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	128	0	1	01	01	H0543_128_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	128	0	1	01	01	H0543_128_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	128	0	1	01	01	H0543_128_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	128	0	1	01	01	H0543_128_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	128	0	1	01	01	H0543_128_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	128	0	1	01	01	H0543_128_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	128	0	1	01	01	H0543_128_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	129	0	1	01	01	H0543_129_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	129	0	1	01	01	H0543_129_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	129	0	1	01	01	H0543_129_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	129	0	1	01	01	H0543_129_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00						20.00			30.00		10.00
H0543	129	0	1	01	01	H0543_129_0	5	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00
H0543	129	0	1	01	01	H0543_129_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0543	129	0	1	01	01	H0543_129_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	129	0	1	01	01	H0543_129_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	131	0	1	01	01	H0543_131_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	131	0	1	01	01	H0543_131_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0543	131	0	1	01	01	H0543_131_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0543	131	0	1	01	01	H0543_131_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	133	0	1	01	01	H0543_133_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	133	0	1	01	01	H0543_133_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	133	0	1	01	01	H0543_133_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	133	0	1	01	01	H0543_133_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	133	0	1	01	01	H0543_133_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	133	0	1	01	01	H0543_133_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	133	0	1	01	01	H0543_133_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	133	0	1	01	01	H0543_133_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	134	0	1	01	01	H0543_134_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	134	0	1	01	01	H0543_134_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	134	0	1	01	01	H0543_134_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	134	0	1	01	01	H0543_134_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	134	0	1	01	01	H0543_134_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	134	0	1	01	01	H0543_134_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	134	0	1	01	01	H0543_134_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	134	0	1	01	01	H0543_134_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	135	0	1	01	01	H0543_135_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	135	0	1	01	01	H0543_135_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	135	0	1	01	01	H0543_135_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	135	0	1	01	01	H0543_135_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	135	0	1	01	01	H0543_135_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	135	0	1	01	01	H0543_135_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	135	0	1	01	01	H0543_135_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	135	0	1	01	01	H0543_135_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	136	0	1	01	01	H0543_136_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	136	0	1	01	01	H0543_136_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	136	0	1	01	01	H0543_136_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	136	0	1	01	01	H0543_136_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	137	0	1	01	01	H0543_137_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	137	0	1	01	01	H0543_137_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	137	0	1	01	01	H0543_137_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	137	0	1	01	01	H0543_137_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	137	0	1	01	01	H0543_137_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	137	0	1	01	01	H0543_137_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	137	0	1	01	01	H0543_137_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	137	0	1	01	01	H0543_137_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	138	0	1	01	01	H0543_138_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	138	0	1	01	01	H0543_138_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	138	0	1	01	01	H0543_138_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						5.00			15.00		5.00
H0543	138	0	1	01	01	H0543_138_0	6	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	138	0	1	01	01	H0543_138_0	6	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0543	138	0	1	01	01	H0543_138_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	138	0	1	01	01	H0543_138_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	138	0	1	01	01	H0543_138_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	139	0	1	01	01	H0543_139_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0543	139	0	1	01	01	H0543_139_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0543	139	0	1	01	01	H0543_139_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0543	139	0	1	01	01	H0543_139_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	139	0	1	01	01	H0543_139_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0543	139	0	1	01	01	H0543_139_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	139	0	1	01	01	H0543_139_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0543	139	0	1	01	01	H0543_139_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0543	140	0	1	01	01	H0543_140_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0543	140	0	1	01	01	H0543_140_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H0543	140	0	1	01	01	H0543_140_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H0543	140	0	1	01	01	H0543_140_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0544	002	0	1	01	01	H0544_002_0	9	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	002	0	1	01	01	H0544_002_0	9	2	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	002	0	1	01	01	H0544_002_0	9	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	002	0	1	01	01	H0544_002_0	9	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	20	20								20			20								20	Injectable Drugs																					
H0544	002	0	1	01	01	H0544_002_0	9	5	4	1	Brand Drugs	000010	3	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00
H0544	002	0	1	01	01	H0544_002_0	9	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00
H0544	002	0	1	01	01	H0544_002_0	9	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	003	0	1	01	01	H0544_003_0	8	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	3	4	3	Enhanced Care Brand Drugs	010010	1	2	2			Enhanced Care Brand Drugs																							Enhanced Care Brand Drugs			Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	003	0	1	01	01	H0544_003_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	003	0	1	01	01	H0544_003_0	8	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	25	25								25			25								25	Injectable Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	1	Brand Drugs	25	25								25			25								25	Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	1	Preferred Brand Drugs	25	25								25			25								25	Preferred Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	1	Enhanced Care Brand Drugs	25	25								25			25								25	Enhanced Care Brand Drugs																					
H0544	003	0	1	01	01	H0544_003_0	8	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	003	0	1	01	01	H0544_003_0	8	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	004	0	1	01	01	H0544_004_0	9	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	20	20								20			20								20	Injectable Drugs																					
H0544	004	0	1	01	01	H0544_004_0	9	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00
H0544	004	0	1	01	01	H0544_004_0	9	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	004	0	1	01	01	H0544_004_0	9	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	004	0	1	01	01	H0544_004_0	9	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	004	0	1	01	01	H0544_004_0	9	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	004	0	1	01	01	H0544_004_0	9	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00
H0544	005	0	1	01	01	H0544_005_0	9	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00
H0544	005	0	1	01	01	H0544_005_0	9	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	005	0	1	01	01	H0544_005_0	9	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	005	0	1	01	01	H0544_005_0	9	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	20	20								20			20								20	Injectable Drugs																					
H0544	005	0	1	01	01	H0544_005_0	9	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00
H0544	005	0	1	01	01	H0544_005_0	9	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H0544	005	0	1	01	01	H0544_005_0	9	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	007	0	1	01	01	H0544_007_0	8	3	4	3	Enhanced Care Brand Drugs	010010	1	2	1		1	Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	25.00	75.00								25.00			50.00								25.00
H0544	007	0	1	01	01	H0544_007_0	8	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			16.00								8.00
H0544	007	0	1	01	01	H0544_007_0	8	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	007	0	1	01	01	H0544_007_0	8	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	30	30								30			30								30	Injectable Drugs																					
H0544	007	0	1	01	01	H0544_007_0	8	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00
H0544	007	0	1	01	01	H0544_007_0	8	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00
H0544	007	0	1	01	01	H0544_007_0	8	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	25.00	75.00								25.00			50.00								25.00
H0544	007	0	1	01	01	H0544_007_0	8	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			16.00								8.00
H0544	007	0	1	01	01	H0544_007_0	8	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	007	0	1	01	01	H0544_007_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	007	0	1	01	01	H0544_007_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	007	0	1	01	01	H0544_007_0	8	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	007	0	1	01	01	H0544_007_0	8	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	007	0	1	01	01	H0544_007_0	8	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	008	0	1	01	01	H0544_008_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	008	0	1	01	01	H0544_008_0	6	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	29.00	87.00								29.00			58.00								29.00
H0544	008	0	1	01	01	H0544_008_0	6	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	008	0	1	01	01	H0544_008_0	6	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	008	0	1	01	01	H0544_008_0	6	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	008	0	1	01	01	H0544_008_0	6	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	20	20								20			20								20	Injectable Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	3	4	3	Enhanced Care Brand Drugs	010010	1	2	1		1	Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	008	0	1	01	01	H0544_008_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	008	0	1	01	01	H0544_008_0	6	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00
H0544	009	0	1	01	01	H0544_009_0	7	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	009	0	1	01	01	H0544_009_0	7	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	009	0	1	01	01	H0544_009_0	7	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	1	Enhanced Care Brand Drugs	25	25								25			25								25	Enhanced Care Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	1	Preferred Brand Drugs	25	25								25			25								25	Preferred Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	1	Brand Drugs	25	25								25			25								25	Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	25	25								25			25								25	Injectable Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	009	0	1	01	01	H0544_009_0	7	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	009	0	1	01	01	H0544_009_0	7	3	4	3	Enhanced Care Brand Drugs	010010	1	2	2			Enhanced Care Brand Drugs																							Enhanced Care Brand Drugs			Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	009	0	1	01	01	H0544_009_0	7	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	010	0	1	01	01	H0544_010_0	8	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	010	0	1	01	01	H0544_010_0	8	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	3	4	3	Enhanced Care Brand Drugs	010010	1	2	1		1	Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	010	0	1	01	01	H0544_010_0	8	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	010	0	1	01	01	H0544_010_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	010	0	1	01	01	H0544_010_0	8	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	20	20								20			20								20	Injectable Drugs																					
H0544	010	0	1	01	01	H0544_010_0	8	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00
H0544	010	0	1	01	01	H0544_010_0	8	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	29.00	87.00								29.00			58.00								29.00
H0544	010	0	1	01	01	H0544_010_0	8	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00
H0544	012	0	1	01	01	H0544_012_0	8	1	4	1	Preferred Generic Drugs	001000	1	2				Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0544	012	0	1	01	01	H0544_012_0	8	6	4	3	Injectable Drugs	010010	1	2	2			Injectable Drugs																							Injectable Drugs			Injectable Drugs																						Injectable Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	5	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	3	4	3	Enhanced Care Brand Drugs	010010	1	2	1		1	Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00
H0544	012	0	1	01	01	H0544_012_0	8	2	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	012	0	1	01	01	H0544_012_0	8	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	93								31										93	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	6	4	1	Injectable Drugs	010010	1	2				Injectable Drugs	111000000010010000000	31	93								31										93	31	Injectable Drugs	2	1	Injectable Drugs	25	25								25			25								25	Injectable Drugs																					
H0544	012	0	1	01	01	H0544_012_0	8	5	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010010000000	31	93								31										93	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00
H0544	012	0	1	01	01	H0544_012_0	8	4	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111000000010010000000	31	93								31										93	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00
H0544	012	0	1	01	01	H0544_012_0	8	3	4	1	Enhanced Care Brand Drugs	010010	1	2				Enhanced Care Brand Drugs	111000000010010000000	31	93								31										93	31	Enhanced Care Brand Drugs	2	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00
H0544	012	0	1	01	01	H0544_012_0	8	2	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	93								31										93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00
H0544	012	0	1	01	01	H0544_012_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	1		1	Preferred Generic Drugs	111000000010010000000	31	93								31										93	31	Preferred Generic Drugs	2	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00
H0545	001	0	1	01	01	H0545_001_0	9	4	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0545	001	0	1	01	01	H0545_001_0	9	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	31	90								31										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	18.00								6.00			12.00								6.00
H0545	001	0	1	01	01	H0545_001_0	9	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00			58.00								29.00
H0545	001	0	1	01	01	H0545_001_0	9	4	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	49.00	147.00								49.00			98.00								49.00
H0545	001	0	1	01	01	H0545_001_0	9	5	4	1	Injectables	010010	1	2				Injectables	111000000010010000000	31	90								31										90	31	Injectables	2	1	Injectables	10	10								10			10								10	Injectables																					
H0545	001	0	1	01	01	H0545_001_0	9	6	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	31									31											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H0545	001	0	1	01	01	H0545_001_0	9	6	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0545	001	0	1	01	01	H0545_001_0	9	5	4	3	Injectables	010010	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0545	001	0	1	01	01	H0545_001_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00
H0545	001	0	1	01	01	H0545_001_0	9	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0545	001	0	1	01	01	H0545_001_0	9	2	4	3	Non-Preferred Generic	000100	3	2	2			Non-Preferred Generic																							Non-Preferred Generic			Non-Preferred Generic																						Non-Preferred Generic																					
H0545	001	0	1	01	01	H0545_001_0	9	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00
H0545	008	0	1	01	01	H0545_008_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	1	Preferred Generic	25	25								25			25								25	Preferred Generic																					
H0545	008	0	1	01	01	H0545_008_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	31	90								31										90	31	Non-Preferred Generic	2	1	Non-Preferred Generic	25	25								25			25								25	Non-Preferred Generic																					
H0545	008	0	1	01	01	H0545_008_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	1	Preferred Brand	25	25								25			25								25	Preferred Brand																					
H0545	008	0	1	01	01	H0545_008_0	7	4	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25			25								25	Non-Preferred Brand																					
H0545	008	0	1	01	01	H0545_008_0	7	5	4	1	Injectables	010010	1	2				Injectables	111000000010010000000	31	90								31										90	31	Injectables	2	1	Injectables	25	25								25			25								25	Injectables																					
H0545	008	0	1	01	01	H0545_008_0	7	6	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	31									31											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H0545	009	0	1	01	01	H0545_009_0	8	6	4	3	Injectables	010010	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0545	009	0	1	01	01	H0545_009_0	8	7	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0545	009	0	1	01	01	H0545_009_0	8	5	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0545	009	0	1	01	01	H0545_009_0	8	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0545	009	0	1	01	01	H0545_009_0	8	3	4	3	Other Special Needs	000010	1	2	1		1	Other Special Needs	111000000010010000000	31	90								31										90	31	Other Special Needs	2	2	Other Special Needs																						Other Special Needs	7.00	21.00								7.00			14.00								7.00
H0545	009	0	1	01	01	H0545_009_0	8	2	4	3	Non-Preferred Generic	000100	3	2	2			Non-Preferred Generic																							Non-Preferred Generic			Non-Preferred Generic																						Non-Preferred Generic																					
H0545	009	0	1	01	01	H0545_009_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00
H0545	009	0	1	01	01	H0545_009_0	8	7	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	31									31											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H0545	009	0	1	01	01	H0545_009_0	8	6	4	1	Injectables	010010	1	2				Injectables	111000000010010000000	31	90								31										90	31	Injectables	2	1	Injectables	10	10								10			10								10	Injectables																					
H0545	009	0	1	01	01	H0545_009_0	8	5	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	49.00	147.00								49.00			98.00								49.00
H0545	009	0	1	01	01	H0545_009_0	8	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00			58.00								29.00
H0545	009	0	1	01	01	H0545_009_0	8	3	4	1	Other Special Needs	000010	1	2				Other Special Needs	111000000010010000000	31	90								31										90	31	Other Special Needs	2	2	Other Special Needs																						Other Special Needs	7.00	21.00								7.00			14.00								7.00
H0545	009	0	1	01	01	H0545_009_0	8	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	31	90								31										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	18.00								6.00			12.00								6.00
H0545	009	0	1	01	01	H0545_009_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00
H0545	011	0	1	01	01	H0545_011_0	8	5	4	1	Injectables	010010	1	2				Injectables	110000000010000000000	31									31											31	Injectables	2	1	Injectables	10									10											10	Injectables																					
H0545	011	0	1	01	01	H0545_011_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	110000000010000000000	31									31											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00									5.00											5.00
H0545	011	0	1	01	01	H0545_011_0	8	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	110000000010000000000	31									31											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	10.00									10.00											10.00
H0545	011	0	1	01	01	H0545_011_0	8	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	110000000010000000000	31									31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00									30.00											30.00
H0545	011	0	1	01	01	H0545_011_0	8	4	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	110000000010000000000	31									31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00									50.00											50.00
H0545	011	0	1	01	01	H0545_011_0	8	6	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	31									31											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H0545	012	0	1	01	01	H0545_012_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	31	92								31										92	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00			9.00								3.00
H0545	012	0	1	01	01	H0545_012_0	4	2	4	3	Non-Preferred Generic	000100	3	2	2			Non-Preferred Generic																							Non-Preferred Generic			Non-Preferred Generic																						Non-Preferred Generic																					
H0545	012	0	1	01	01	H0545_012_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0545	012	0	1	01	01	H0545_012_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0545	012	0	1	01	01	H0545_012_0	4	5	4	3	Injectables	010010	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H0545	012	0	1	01	01	H0545_012_0	4	6	4	1	Specialty Drugs	100000	1	1				Specialty Drugs	111000000010010000000	31	92								31										92	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0545	012	0	1	01	01	H0545_012_0	4	5	4	1	Injectables	010010	1	2				Injectables	111000000010010000000	31	92								31										92	31	Injectables	2	1	Injectables	20	20								20			20								20	Injectables																					
H0545	012	0	1	01	01	H0545_012_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	92								31										92	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H0545	012	0	1	01	01	H0545_012_0	4	6	4	3	Specialty Drugs	100000	1	1	1		1	Specialty Drugs	111000000010010000000	31	92								31										92	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H0545	012	0	1	01	01	H0545_012_0	4	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	31	92								31										92	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	10.00	30.00								10.00			30.00								10.00
H0545	012	0	1	01	01	H0545_012_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	31	92								31										92	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00			9.00								3.00
H0545	012	0	1	01	01	H0545_012_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	92								31										92	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H0562	002	0	1	01	01	H0562_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	002	0	1	01	01	H0562_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	002	0	1	01	01	H0562_002_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	002	0	1	01	01	H0562_002_0	5	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	002	0	1	01	01	H0562_002_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	002	0	1	01	01	H0562_002_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	002	0	1	01	01	H0562_002_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	002	0	1	01	01	H0562_002_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	002	0	1	01	01	H0562_002_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	002	0	1	01	01	H0562_002_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	009	0	1	01	01	H0562_009_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	009	0	1	01	01	H0562_009_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	009	0	1	01	01	H0562_009_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	009	0	1	01	01	H0562_009_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	009	0	1	01	01	H0562_009_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	010	0	1	01	01	H0562_010_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	010	0	1	01	01	H0562_010_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	010	0	1	01	01	H0562_010_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	010	0	1	01	01	H0562_010_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	010	0	1	01	01	H0562_010_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	011	0	1	01	01	H0562_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	011	0	1	01	01	H0562_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	011	0	1	01	01	H0562_011_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	011	0	1	01	01	H0562_011_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	011	0	1	01	01	H0562_011_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	012	0	1	01	01	H0562_012_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	012	0	1	01	01	H0562_012_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	012	0	1	01	01	H0562_012_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	012	0	1	01	01	H0562_012_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	012	0	1	01	01	H0562_012_0	5	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	012	0	1	01	01	H0562_012_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	012	0	1	01	01	H0562_012_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	012	0	1	01	01	H0562_012_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	012	0	1	01	01	H0562_012_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	012	0	1	01	01	H0562_012_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	017	0	1	01	01	H0562_017_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	017	0	1	01	01	H0562_017_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	017	0	1	01	01	H0562_017_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	017	0	1	01	01	H0562_017_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	017	0	1	01	01	H0562_017_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	036	0	1	01	01	H0562_036_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	036	0	1	01	01	H0562_036_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	036	0	1	01	01	H0562_036_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	036	0	1	01	01	H0562_036_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	036	0	1	01	01	H0562_036_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	037	0	1	01	01	H0562_037_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	037	0	1	01	01	H0562_037_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	037	0	1	01	01	H0562_037_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	037	0	1	01	01	H0562_037_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	037	0	1	01	01	H0562_037_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	039	0	1	01	01	H0562_039_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	039	0	1	01	01	H0562_039_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	039	0	1	01	01	H0562_039_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	039	0	1	01	01	H0562_039_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	039	0	1	01	01	H0562_039_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	040	0	1	01	01	H0562_040_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	040	0	1	01	01	H0562_040_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	040	0	1	01	01	H0562_040_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	040	0	1	01	01	H0562_040_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	040	0	1	01	01	H0562_040_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	053	0	1	01	01	H0562_053_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	053	0	1	01	01	H0562_053_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	053	0	1	01	01	H0562_053_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	053	0	1	01	01	H0562_053_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	053	0	1	01	01	H0562_053_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	056	0	1	01	01	H0562_056_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	056	0	1	01	01	H0562_056_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	056	0	1	01	01	H0562_056_0	3	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	056	0	1	01	01	H0562_056_0	3	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	056	0	1	01	01	H0562_056_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	056	0	1	01	01	H0562_056_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	056	0	1	01	01	H0562_056_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	056	0	1	01	01	H0562_056_0	3	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	056	0	1	01	01	H0562_056_0	3	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	056	0	1	01	01	H0562_056_0	3	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	058	0	1	01	01	H0562_058_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	058	0	1	01	01	H0562_058_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	058	0	1	01	01	H0562_058_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	058	0	1	01	01	H0562_058_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	058	0	1	01	01	H0562_058_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	059	0	1	01	01	H0562_059_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	059	0	1	01	01	H0562_059_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	059	0	1	01	01	H0562_059_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	059	0	1	01	01	H0562_059_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	059	0	1	01	01	H0562_059_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	060	0	1	01	01	H0562_060_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	060	0	1	01	01	H0562_060_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	060	0	1	01	01	H0562_060_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	060	0	1	01	01	H0562_060_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	060	0	1	01	01	H0562_060_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	061	0	1	01	01	H0562_061_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	061	0	1	01	01	H0562_061_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	061	0	1	01	01	H0562_061_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	061	0	1	01	01	H0562_061_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	061	0	1	01	01	H0562_061_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	062	0	1	01	01	H0562_062_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	062	0	1	01	01	H0562_062_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	062	0	1	01	01	H0562_062_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	062	0	1	01	01	H0562_062_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	062	0	1	01	01	H0562_062_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	068	0	1	01	01	H0562_068_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	068	0	1	01	01	H0562_068_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	068	0	1	01	01	H0562_068_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	068	0	1	01	01	H0562_068_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	068	0	1	01	01	H0562_068_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	071	0	1	01	01	H0562_071_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	071	0	1	01	01	H0562_071_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	071	0	1	01	01	H0562_071_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	071	0	1	01	01	H0562_071_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	071	0	1	01	01	H0562_071_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	071	0	1	01	01	H0562_071_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	071	0	1	01	01	H0562_071_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	071	0	1	01	01	H0562_071_0	4	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	071	0	1	01	01	H0562_071_0	4	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	071	0	1	01	01	H0562_071_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	072	0	1	01	01	H0562_072_0	8	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	072	0	1	01	01	H0562_072_0	8	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	072	0	1	01	01	H0562_072_0	8	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	072	0	1	01	01	H0562_072_0	8	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	072	0	1	01	01	H0562_072_0	8	2	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	072	0	1	01	01	H0562_072_0	8	1	4	3	Preferred Generics	001000	1	2	1		1	Preferred Generics	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0562	072	0	1	01	01	H0562_072_0	8	6	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	072	0	1	01	01	H0562_072_0	8	5	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	072	0	1	01	01	H0562_072_0	8	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	072	0	1	01	01	H0562_072_0	8	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	072	0	1	01	01	H0562_072_0	8	2	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	072	0	1	01	01	H0562_072_0	8	1	4	1	Preferred Generics	001000	1	2				Preferred Generics	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0562	076	0	1	01	01	H0562_076_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	076	0	1	01	01	H0562_076_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	076	0	1	01	01	H0562_076_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	076	0	1	01	01	H0562_076_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	076	0	1	01	01	H0562_076_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	077	0	1	01	01	H0562_077_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	077	0	1	01	01	H0562_077_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	077	0	1	01	01	H0562_077_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	077	0	1	01	01	H0562_077_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	077	0	1	01	01	H0562_077_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	079	0	1	01	01	H0562_079_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0562	079	0	1	01	01	H0562_079_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0562	079	0	1	01	01	H0562_079_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H0562	079	0	1	01	01	H0562_079_0	5	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0562	079	0	1	01	01	H0562_079_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0562	079	0	1	01	01	H0562_079_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0562	079	0	1	01	01	H0562_079_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0562	079	0	1	01	01	H0562_079_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0562	079	0	1	01	01	H0562_079_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0562	079	0	1	01	01	H0562_079_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H0564	006	0	1	01	01	H0564_006_0	12	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H0564	006	0	1	01	01	H0564_006_0	12	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H0564	006	0	1	01	01	H0564_006_0	12	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0564	006	0	1	01	01	H0564_006_0	12	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H0564	006	0	1	01	01	H0564_006_0	12	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H0564	006	0	1	01	01	H0564_006_0	12	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H0564	006	0	1	01	01	H0564_006_0	12	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H0564	006	0	1	01	01	H0564_006_0	12	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H0564	006	0	1	01	01	H0564_006_0	12	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H0564	006	0	1	01	01	H0564_006_0	12	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H0571	001	0	1	01	01	H0571_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00
H0571	001	0	1	01	01	H0571_001_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	1	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00
H0571	002	0	2	01	01	H0571_002_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00
H0571	002	0	2	01	01	H0571_002_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	1	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00
H0571	006	0	1	01	01	H0571_006_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00
H0571	006	0	1	01	01	H0571_006_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	1	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00
H0602	017	0	1	18	06	H0602_017_0	9	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.00	180.00								60.00			120.00								60.00
H0602	017	0	1	18	06	H0602_017_0	9	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.00	120.00								40.00			80.00								40.00
H0602	017	0	1	18	06	H0602_017_0	9	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	017	0	1	18	06	H0602_017_0	9	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.00	27.00								9.00			18.00								9.00
H0602	018	0	1	18	06	H0602_018_0	10	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	58.00	174.00								58.00			116.00								58.00
H0602	018	0	1	18	06	H0602_018_0	10	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	018	0	1	18	06	H0602_018_0	10	1	4	3	Generic drugs	010000	1	2	1		1	Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	018	0	1	18	06	H0602_018_0	10	2	4	3	Preferred Brand drugs	000001	1	2	2			Preferred Brand drugs																							Preferred Brand drugs			Preferred Brand drugs																						Preferred Brand drugs																					
H0602	018	0	1	18	06	H0602_018_0	10	3	4	3	Non-preferred Brand drugs	100000	1	2	2			Non-preferred Brand drugs																							Non-preferred Brand drugs			Non-preferred Brand drugs																						Non-preferred Brand drugs																					
H0602	018	0	1	18	06	H0602_018_0	10	4	4	3	Specialty drugs	010010	1	1	2			Specialty drugs																							Specialty drugs			Specialty drugs																						Specialty drugs																					
H0602	018	0	1	18	06	H0602_018_0	10	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	018	0	1	18	06	H0602_018_0	10	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	38.00	114.00								38.00			76.00								38.00
H0602	019	0	1	18	06	H0602_019_0	9	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	56.00	168.00								56.00			112.00								56.00
H0602	019	0	1	18	06	H0602_019_0	9	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	019	0	1	18	06	H0602_019_0	9	1	4	3	Generic drugs	010000	1	2	1		1	Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	019	0	1	18	06	H0602_019_0	9	2	4	3	Preferred Brand drugs	000001	1	2	2			Preferred Brand drugs																							Preferred Brand drugs			Preferred Brand drugs																						Preferred Brand drugs																					
H0602	019	0	1	18	06	H0602_019_0	9	3	4	3	Non-preferred Brand drugs	100000	1	2	2			Non-preferred Brand drugs																							Non-preferred Brand drugs			Non-preferred Brand drugs																						Non-preferred Brand drugs																					
H0602	019	0	1	18	06	H0602_019_0	9	4	4	3	Specialty drugs	010010	1	1	2			Specialty drugs																							Specialty drugs			Specialty drugs																						Specialty drugs																					
H0602	019	0	1	18	06	H0602_019_0	9	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	019	0	1	18	06	H0602_019_0	9	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	36.00	108.00								36.00			72.00								36.00
H0602	020	0	1	18	06	H0602_020_0	10	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.00	180.00								60.00			120.00								60.00
H0602	020	0	1	18	06	H0602_020_0	10	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.00	27.00								9.00			18.00								9.00
H0602	020	0	1	18	06	H0602_020_0	10	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	020	0	1	18	06	H0602_020_0	10	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.00	120.00								40.00			80.00								40.00
H0602	021	0	1	18	06	H0602_021_0	9	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	58.00	174.00								58.00			116.00								58.00
H0602	021	0	1	18	06	H0602_021_0	9	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	021	0	1	18	06	H0602_021_0	9	1	4	3	Generic drugs	010000	1	2	1		1	Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	021	0	1	18	06	H0602_021_0	9	2	4	3	Preferred Brand drugs	000001	1	2	2			Preferred Brand drugs																							Preferred Brand drugs			Preferred Brand drugs																						Preferred Brand drugs																					
H0602	021	0	1	18	06	H0602_021_0	9	3	4	3	Non-preferred Brand drugs	100000	1	2	2			Non-preferred Brand drugs																							Non-preferred Brand drugs			Non-preferred Brand drugs																						Non-preferred Brand drugs																					
H0602	021	0	1	18	06	H0602_021_0	9	4	4	3	Specialty drugs	010010	1	1	2			Specialty drugs																							Specialty drugs			Specialty drugs																						Specialty drugs																					
H0602	021	0	1	18	06	H0602_021_0	9	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	021	0	1	18	06	H0602_021_0	9	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	38.00	114.00								38.00			76.00								38.00
H0602	022	0	1	18	06	H0602_022_0	13	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.00	180.00								60.00			120.00								60.00
H0602	022	0	1	18	06	H0602_022_0	13	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.00	27.00								9.00			18.00								9.00
H0602	022	0	1	18	06	H0602_022_0	13	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	022	0	1	18	06	H0602_022_0	13	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.00	120.00								40.00			80.00								40.00
H0602	023	0	1	18	06	H0602_023_0	10	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.00	180.00								60.00			120.00								60.00
H0602	023	0	1	18	06	H0602_023_0	10	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.00	27.00								9.00			18.00								9.00
H0602	023	0	1	18	06	H0602_023_0	10	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	023	0	1	18	06	H0602_023_0	10	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.00	120.00								40.00			80.00								40.00
H0602	024	0	1	18	06	H0602_024_0	10	3	4	1	Non-preferred Brand drugs	100000	1	2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	56.00	168.00								56.00			112.00								56.00
H0602	024	0	1	18	06	H0602_024_0	10	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	024	0	1	18	06	H0602_024_0	10	1	4	3	Generic drugs	010000	1	2	1		1	Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.50	25.50								8.50			17.00								8.50
H0602	024	0	1	18	06	H0602_024_0	10	2	4	3	Preferred Brand drugs	000001	1	2	2			Preferred Brand drugs																							Preferred Brand drugs			Preferred Brand drugs																						Preferred Brand drugs																					
H0602	024	0	1	18	06	H0602_024_0	10	3	4	3	Non-preferred Brand drugs	100000	1	2	2			Non-preferred Brand drugs																							Non-preferred Brand drugs			Non-preferred Brand drugs																						Non-preferred Brand drugs																					
H0602	024	0	1	18	06	H0602_024_0	10	4	4	3	Specialty drugs	010010	1	1	2			Specialty drugs																							Specialty drugs			Specialty drugs																						Specialty drugs																					
H0602	024	0	1	18	06	H0602_024_0	10	4	4	1	Specialty drugs	010010	1	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
H0602	024	0	1	18	06	H0602_024_0	10	2	4	1	Preferred Brand drugs	000001	1	2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	36.00	108.00								36.00			72.00								36.00
H0602	036	0	1	18	06	H0602_036_0	11	3	3	1	Non-preferred Brand drugs	100000		2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.50	181.50								60.50			121.00								60.50
H0602	036	0	1	18	06	H0602_036_0	11	1	3	1	Generic drugs	010000		2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.25	27.75								9.25			18.50								9.25
H0602	036	0	1	18	06	H0602_036_0	11	4	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	30	30								30			30								30	Specialty drugs																					
H0602	036	0	1	18	06	H0602_036_0	11	2	3	1	Preferred Brand drugs	000001		2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.50	121.50								40.50			81.00								40.50
H0602	037	0	1	18	06	H0602_037_0	11	2	3	1	Preferred Brand drugs	000001		2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.50	121.50								40.50			81.00								40.50
H0602	037	0	1	18	06	H0602_037_0	11	1	3	1	Generic drugs	010000		2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.25	27.75								9.25			18.50								9.25
H0602	037	0	1	18	06	H0602_037_0	11	3	3	1	Non-preferred Brand drugs	100000		2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.50	181.50								60.50			121.00								60.50
H0602	037	0	1	18	06	H0602_037_0	11	4	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	30	30								30			30								30	Specialty drugs																					
H0602	038	0	1	18	06	H0602_038_0	12	3	3	1	Non-preferred Brand drugs	100000		2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.50	181.50								60.50			121.00								60.50
H0602	038	0	1	18	06	H0602_038_0	12	2	3	1	Preferred Brand drugs	000001		2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.50	121.50								40.50			81.00								40.50
H0602	038	0	1	18	06	H0602_038_0	12	1	3	1	Generic drugs	010000		2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.25	27.75								9.25			18.50								9.25
H0602	038	0	1	18	06	H0602_038_0	12	4	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	30	30								30			30								30	Specialty drugs																					
H0602	039	0	1	18	06	H0602_039_0	11	3	3	1	Non-preferred Brand drugs	100000		2				Non-preferred Brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred Brand drugs	2	2	Non-preferred Brand drugs																						Non-preferred Brand drugs	60.50	181.50								60.50			121.00								60.50
H0602	039	0	1	18	06	H0602_039_0	11	4	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	30	30								30			30								30	Specialty drugs																					
H0602	039	0	1	18	06	H0602_039_0	11	1	3	1	Generic drugs	010000		2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.25	27.75								9.25			18.50								9.25
H0602	039	0	1	18	06	H0602_039_0	11	2	3	1	Preferred Brand drugs	000001		2				Preferred Brand drugs	111000000010010000000	30	90								30										90	31	Preferred Brand drugs	2	2	Preferred Brand drugs																						Preferred Brand drugs	40.50	121.50								40.50			81.00								40.50
H0609	002	0	1	01	01	H0609_002_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0609	002	0	1	01	01	H0609_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	002	0	1	01	01	H0609_002_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	002	0	1	01	01	H0609_002_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	002	0	1	01	01	H0609_002_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0609	002	0	1	01	01	H0609_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	002	0	1	01	01	H0609_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0609	002	0	1	01	01	H0609_002_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	006	0	1	01	01	H0609_006_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	006	0	1	01	01	H0609_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	006	0	1	01	01	H0609_006_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	006	0	1	01	01	H0609_006_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	007	0	1	01	01	H0609_007_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	007	0	1	01	01	H0609_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	007	0	1	01	01	H0609_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	007	0	1	01	01	H0609_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	011	0	1	01	01	H0609_011_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	011	0	1	01	01	H0609_011_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	011	0	1	01	01	H0609_011_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	011	0	1	01	01	H0609_011_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	012	0	1	01	01	H0609_012_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	012	0	1	01	01	H0609_012_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	012	0	1	01	01	H0609_012_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	012	0	1	01	01	H0609_012_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	013	0	1	01	01	H0609_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	013	0	1	01	01	H0609_013_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0609	013	0	1	01	01	H0609_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	013	0	1	01	01	H0609_013_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	020	0	1	01	01	H0609_020_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0609	020	0	1	01	01	H0609_020_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H0609	020	0	1	01	01	H0609_020_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H0609	020	0	1	01	01	H0609_020_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0620	002	0	1	04	01	H0620_002_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0620	002	0	1	04	01	H0620_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0620	002	0	1	04	01	H0620_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0620	002	0	1	04	01	H0620_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0621	004	0	1	01	01	H0621_004_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00		78.00	156.00								78.00
H0621	004	0	1	01	01	H0621_004_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00		38.00	76.00								38.00
H0621	004	0	1	01	01	H0621_004_0	8	1	4	1	Tier 1	011000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00
H0621	004	0	1	01	01	H0621_004_0	8	1	4	3	Tier 1	011000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00
H0621	004	0	1	01	01	H0621_004_0	8	4	4	1	Tier 4	000001	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H0621	004	0	1	01	01	H0621_004_0	8	2	4	3	Tier 2	000001	1	2	1		1	Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	1	Tier 2	50	50								50		40	40								50	Tier 2																					
H0621	004	0	1	01	01	H0621_004_0	8	3	4	3	Tier 3	100000	1	2	1		1	Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	1	Tier 3	60	60								60		50	50								60	Tier 3																					
H0621	004	0	1	01	01	H0621_004_0	8	4	4	3	Tier 4	000001	1	1	1		1	Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	60	60								60		50	50								60	Tier 4																					
H0621	005	0	1	01	01	H0621_005_0	8	3	4	3	Tier 3	100000	1	2	1		1	Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	1	Tier 3	60	60								60		50	50								60	Tier 3																					
H0621	005	0	1	01	01	H0621_005_0	8	2	4	3	Tier 2	000001	1	2	1		1	Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	1	Tier 2	50	50								50		40	40								50	Tier 2																					
H0621	005	0	1	01	01	H0621_005_0	8	1	4	3	Tier 1	011000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00
H0621	005	0	1	01	01	H0621_005_0	8	4	4	1	Tier 4	000001	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H0621	005	0	1	01	01	H0621_005_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00		78.00	156.00								78.00
H0621	005	0	1	01	01	H0621_005_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00		38.00	76.00								38.00
H0621	005	0	1	01	01	H0621_005_0	8	4	4	3	Tier 4	000001	1	1	1		1	Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	60	60								60		50	50								60	Tier 4																					
H0621	005	0	1	01	01	H0621_005_0	8	1	4	1	Tier 1	011000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00
H0621	006	0	1	01	01	H0621_006_0	7	1	3	1	Tier 1	011000		2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	12.00								6.00
H0621	006	0	1	01	01	H0621_006_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00		78.00	156.00								78.00
H0621	006	0	1	01	01	H0621_006_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00		38.00	76.00								38.00
H0621	006	0	1	01	01	H0621_006_0	7	4	3	1	Tier 4	000001		1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H0621	007	0	1	01	01	H0621_007_0	6	4	4	3	Tier 4	000001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0621	007	0	1	01	01	H0621_007_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0621	007	0	1	01	01	H0621_007_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0621	007	0	1	01	01	H0621_007_0	6	1	4	3	Tier 1	011000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	12.00								6.00
H0621	007	0	1	01	01	H0621_007_0	6	4	4	1	Tier 4	000001	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H0621	007	0	1	01	01	H0621_007_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00		78.00	156.00								78.00
H0621	007	0	1	01	01	H0621_007_0	6	1	4	1	Tier 1	011000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	12.00								6.00
H0621	007	0	1	01	01	H0621_007_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00		38.00	76.00								38.00
H0623	001	0	1	04	01	H0623_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	001	0	1	04	01	H0623_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	001	0	1	04	01	H0623_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0623	001	0	1	04	01	H0623_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	001	0	1	04	01	H0623_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	001	0	1	04	01	H0623_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	001	0	1	04	01	H0623_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0623	001	0	1	04	01	H0623_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	005	0	1	04	01	H0623_005_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	005	0	1	04	01	H0623_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	005	0	1	04	01	H0623_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	005	0	1	04	01	H0623_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0623	005	0	1	04	01	H0623_005_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	005	0	1	04	01	H0623_005_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	005	0	1	04	01	H0623_005_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	005	0	1	04	01	H0623_005_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0623	007	0	1	04	01	H0623_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	007	0	1	04	01	H0623_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	007	0	1	04	01	H0623_007_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	007	0	1	04	01	H0623_007_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0623	007	0	1	04	01	H0623_007_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H0623	007	0	1	04	01	H0623_007_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H0623	007	0	1	04	01	H0623_007_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0623	007	0	1	04	01	H0623_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H0624	004	0	1	01	01	H0624_004_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0624	004	0	1	01	01	H0624_004_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0624	004	0	1	01	01	H0624_004_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0624	004	0	1	01	01	H0624_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0624	005	0	1	01	01	H0624_005_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0624	005	0	1	01	01	H0624_005_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0624	005	0	1	01	01	H0624_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0624	005	0	1	01	01	H0624_005_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0630	013	0	1	01	01	H0630_013_0	8	2	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010110000000	30	90								30		30								90	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00
H0630	013	0	1	01	01	H0630_013_0	8	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00
H0630	013	0	1	01	01	H0630_013_0	8	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H0630	013	0	1	01	01	H0630_013_0	8	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00
H0630	013	0	1	01	01	H0630_013_0	8	2	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0630	013	0	1	01	01	H0630_013_0	8	3	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0630	015	0	1	01	01	H0630_015_0	6	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	21.00								7.00		7.00	14.00								7.00
H0630	015	0	1	01	01	H0630_015_0	6	2	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010110000000	30	90								30		30								90	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00
H0630	015	0	1	01	01	H0630_015_0	6	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H0630	015	0	1	01	01	H0630_015_0	6	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	21.00								7.00		7.00	14.00								7.00
H0630	015	0	1	01	01	H0630_015_0	6	2	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0630	015	0	1	01	01	H0630_015_0	6	3	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0630	016	0	1	01	01	H0630_016_0	7	2	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010110000000	30	90								30		30								90	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	30.00	90.00								30.00		30.00	60.00								30.00
H0630	016	0	1	01	01	H0630_016_0	7	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	6.00	18.00								6.00		6.00	12.00								6.00
H0630	016	0	1	01	01	H0630_016_0	7	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H0630	016	0	1	01	01	H0630_016_0	7	3	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0630	016	0	1	01	01	H0630_016_0	7	2	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0630	016	0	1	01	01	H0630_016_0	7	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	6.00	18.00								6.00		6.00	12.00								6.00
H0630	017	0	1	01	01	H0630_017_0	8	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	9.00	27.00								9.00		9.00	18.00								9.00
H0630	017	0	1	01	01	H0630_017_0	8	2	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010110000000	30	90								30		30								90	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00
H0630	017	0	1	01	01	H0630_017_0	8	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H0630	017	0	1	01	01	H0630_017_0	8	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	9.00	27.00								9.00		9.00	18.00								9.00
H0630	017	0	1	01	01	H0630_017_0	8	2	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0630	017	0	1	01	01	H0630_017_0	8	3	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0630	018	0	1	01	01	H0630_018_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00
H0630	018	0	1	01	01	H0630_018_0	5	2	4	1	Brand Drugs	000010	1	2				Brand Drugs	111000000010110000000	30	90								30		30								90	31	Brand Drugs	2	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00
H0630	018	0	1	01	01	H0630_018_0	5	2	4	3	Brand Drugs	000010	1	2	2			Brand Drugs																							Brand Drugs			Brand Drugs																						Brand Drugs																					
H0630	018	0	1	01	01	H0630_018_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010110000000	30	90								30		30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00
H0630	018	0	1	01	01	H0630_018_0	5	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H0630	018	0	1	01	01	H0630_018_0	5	3	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H0710	001	0	1	04	01	H0710_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H0710	001	0	1	04	01	H0710_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0710	001	0	1	04	01	H0710_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H0710	001	0	1	04	01	H0710_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0710	003	0	1	04	01	H0710_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H0710	003	0	1	04	01	H0710_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H0710	003	0	1	04	01	H0710_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0710	003	0	1	04	01	H0710_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H0712	001	0	1	02	01	H0712_001_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0712	001	0	1	02	01	H0712_001_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H0712	001	0	1	02	01	H0712_001_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0712	001	0	1	02	01	H0712_001_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0712	005	0	1	01	01	H0712_005_0	9	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
H0712	005	0	1	01	01	H0712_005_0	9	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0712	005	0	1	01	01	H0712_005_0	9	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H0712	005	0	1	01	01	H0712_005_0	9	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0712	011	0	1	02	01	H0712_011_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H0712	011	0	1	02	01	H0712_011_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H0712	011	0	1	02	01	H0712_011_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0712	011	0	1	02	01	H0712_011_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0712	018	0	1	02	01	H0712_018_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0712	018	0	1	02	01	H0712_018_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0712	018	0	1	02	01	H0712_018_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00
H0712	018	0	1	02	01	H0712_018_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H0747	007	0	1	09	04	H0747_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
H0747	007	0	1	09	04	H0747_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H0747	007	0	1	09	04	H0747_007_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	12.00								5.00			12.00								5.00
H0747	007	0	1	09	04	H0747_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	66.00								25.00			66.00								25.00
H0747	008	0	1	09	04	H0747_008_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	12.00								5.00			12.00								5.00
H0747	008	0	1	09	04	H0747_008_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	66.00								25.00			66.00								25.00
H0747	008	0	1	09	04	H0747_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H0747	008	0	1	09	04	H0747_008_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
H0747	010	0	1	09	04	H0747_010_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	12.00								5.00			12.00								5.00
H0747	010	0	1	09	04	H0747_010_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	66.00								25.00			66.00								25.00
H0747	010	0	1	09	04	H0747_010_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H0747	010	0	1	09	04	H0747_010_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
H0752	002	0	1	01	01	H0752_002_0	11	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H0752	002	0	1	01	01	H0752_002_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0752	002	0	1	01	01	H0752_002_0	11	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H0752	002	0	1	01	01	H0752_002_0	11	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H0752	002	0	1	01	01	H0752_002_0	11	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H0752	002	0	1	01	01	H0752_002_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H0752	002	0	1	01	01	H0752_002_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H0752	002	0	1	01	01	H0752_002_0	11	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0755	001	0	1	01	01	H0755_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	001	0	1	01	01	H0755_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H0755	001	0	1	01	01	H0755_001_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
H0755	001	0	1	01	01	H0755_001_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0755	001	0	1	01	01	H0755_001_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0755	001	0	1	01	01	H0755_001_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	001	0	1	01	01	H0755_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0755	001	0	1	01	01	H0755_001_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0755	001	0	1	01	01	H0755_001_0	5	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0755	001	0	1	01	01	H0755_001_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0755	020	0	1	02	01	H0755_020_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	020	0	1	02	01	H0755_020_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H0755	020	0	1	02	01	H0755_020_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
H0755	020	0	1	02	01	H0755_020_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0755	020	0	1	02	01	H0755_020_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0755	020	0	1	02	01	H0755_020_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	020	0	1	02	01	H0755_020_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0755	020	0	1	02	01	H0755_020_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0755	020	0	1	02	01	H0755_020_0	5	4	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0755	020	0	1	02	01	H0755_020_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0755	022	0	1	01	01	H0755_022_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	022	0	1	01	01	H0755_022_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0755	022	0	1	01	01	H0755_022_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0755	022	0	1	01	01	H0755_022_0	4	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
H0755	022	0	1	01	01	H0755_022_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H0755	027	0	1	01	01	H0755_027_0	6	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H0755	027	0	1	01	01	H0755_027_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0755	027	0	1	01	01	H0755_027_0	6	4	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H0755	027	0	1	01	01	H0755_027_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0755	027	0	1	01	01	H0755_027_0	6	2	4	3	Preferred Generic	001000	1	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H0755	027	0	1	01	01	H0755_027_0	6	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H0755	027	0	1	01	01	H0755_027_0	6	6	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0755	027	0	1	01	01	H0755_027_0	6	5	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	2	1	Injectable	33									33					33			33			33	Injectable																					
H0755	027	0	1	01	01	H0755_027_0	6	4	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H0755	027	0	1	01	01	H0755_027_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H0755	027	0	1	01	01	H0755_027_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
H0755	027	0	1	01	01	H0755_027_0	6	2	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H0755	028	0	1	01	01	H0755_028_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H0755	028	0	1	01	01	H0755_028_0	4	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
H0755	028	0	1	01	01	H0755_028_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H0755	028	0	1	01	01	H0755_028_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00						16.00	16.00	8.00	24.00	16.00	8.00
H0755	028	0	1	01	01	H0755_028_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H0768	001	0	1	04	01	H0768_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
H0768	001	0	1	04	01	H0768_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H0768	001	0	1	04	01	H0768_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H0768	001	0	1	04	01	H0768_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H0768	001	0	1	04	01	H0768_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H0768	002	0	1	04	01	H0768_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H0768	002	0	1	04	01	H0768_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H0768	002	0	1	04	01	H0768_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H0768	002	0	1	04	01	H0768_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H0768	002	0	1	04	01	H0768_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H0806	001	0	1	02	01	H0806_001_0	5	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H0806	001	0	1	02	01	H0806_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0806	001	0	1	02	01	H0806_001_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H0806	001	0	1	02	01	H0806_001_0	5	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H0806	001	0	1	02	01	H0806_001_0	5	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	51.00	153.00								51.00			153.00								51.00
H0806	001	0	1	02	01	H0806_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H0806	001	0	1	02	01	H0806_001_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H0806	001	0	1	02	01	H0806_001_0	5	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H0806	002	0	1	02	01	H0806_002_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H0806	002	0	1	02	01	H0806_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H0806	002	0	1	02	01	H0806_002_0	5	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H0806	002	0	1	02	01	H0806_002_0	5	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H0806	002	0	1	02	01	H0806_002_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H0806	002	0	1	02	01	H0806_002_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H0806	002	0	1	02	01	H0806_002_0	5	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H0806	002	0	1	02	01	H0806_002_0	5	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H0806	003	0	1	02	01	H0806_003_0	5	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	71.00	213.00								71.00			213.00								71.00
H0806	003	0	1	02	01	H0806_003_0	5	4	3	1	Specialty - Generic and Brand	010010		1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H0806	003	0	1	02	01	H0806_003_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H0806	003	0	1	02	01	H0806_003_0	5	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H0846	014	0	1	09	04	H0846_014_0	5	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H0846	014	0	1	09	04	H0846_014_0	5	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	74.00	222.00								74.00			222.00								74.00
H0846	014	0	1	09	04	H0846_014_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H0846	014	0	1	09	04	H0846_014_0	5	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H0846	015	0	1	09	04	H0846_015_0	5	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H0846	015	0	1	09	04	H0846_015_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H0846	015	0	1	09	04	H0846_015_0	5	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	73.00	219.00								73.00			219.00								73.00
H0846	015	0	1	09	04	H0846_015_0	5	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H0901	002	0	1	01	01	H0901_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H0901	002	0	1	01	01	H0901_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H0901	002	0	1	01	01	H0901_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H0901	002	0	1	01	01	H0901_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H0901	002	0	1	01	01	H0901_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0901	002	0	1	01	01	H0901_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H0901	002	0	1	01	01	H0901_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H0901	002	0	1	01	01	H0901_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0901	002	0	1	01	01	H0901_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0901	002	0	1	01	01	H0901_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H0901	004	0	1	01	01	H0901_004_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H0901	004	0	1	01	01	H0901_004_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H0901	004	0	1	01	01	H0901_004_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H0901	004	0	1	01	01	H0901_004_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H0901	004	0	1	01	01	H0901_004_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H0901	005	0	1	01	01	H0901_005_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H0901	005	0	1	01	01	H0901_005_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H0901	005	0	1	01	01	H0901_005_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					58.00			87.00		29.00
H0901	005	0	1	01	01	H0901_005_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H0901	005	0	1	01	01	H0901_005_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H0901	007	0	1	01	01	H0901_007_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H0901	007	0	1	01	01	H0901_007_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H0901	007	0	1	01	01	H0901_007_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H0901	007	0	1	01	01	H0901_007_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H0901	007	0	1	01	01	H0901_007_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H0902	002	0	1	04	01	H0902_002_0	9	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H0902	002	0	1	04	01	H0902_002_0	9	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H0902	002	0	1	04	01	H0902_002_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H0902	002	0	1	04	01	H0902_002_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H0902	002	0	1	04	01	H0902_002_0	9	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H0902	002	0	1	04	01	H0902_002_0	9	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H0902	002	0	1	04	01	H0902_002_0	9	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H0902	002	0	1	04	01	H0902_002_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H0902	002	0	1	04	01	H0902_002_0	9	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H0902	002	0	1	04	01	H0902_002_0	9	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H0908	001	0	1	01	01	H0908_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	94.00	282.00								94.00			282.00								94.00
H0908	001	0	1	01	01	H0908_001_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	44.00	132.00								44.00			132.00								44.00
H0908	001	0	1	01	01	H0908_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H0908	001	0	1	01	01	H0908_001_0	6	4	4	1	Injectable	000001	1	2				Injectable	111000000010010000000	30	90								30										90	31	Injectable	2	2	Injectable																						Injectable	44.00	132.00								44.00			132.00								44.00
H0913	001	0	1	01	01	H0913_001_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0913	001	0	1	01	01	H0913_001_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0913	001	0	1	01	01	H0913_001_0	9	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0913	001	0	1	01	01	H0913_001_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	001	0	1	01	01	H0913_001_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0913	001	0	1	01	01	H0913_001_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H0913	001	0	1	01	01	H0913_001_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0913	001	0	1	01	01	H0913_001_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	002	0	1	01	01	H0913_002_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	002	0	1	01	01	H0913_002_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H0913	002	0	1	01	01	H0913_002_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H0913	002	0	1	01	01	H0913_002_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H0913	002	0	1	01	01	H0913_002_0	7	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H0913	002	0	1	01	01	H0913_002_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	002	0	1	01	01	H0913_002_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0913	002	0	1	01	01	H0913_002_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H0913	003	0	1	01	01	H0913_003_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	003	0	1	01	01	H0913_003_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H0913	003	0	1	01	01	H0913_003_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00
H0913	003	0	1	01	01	H0913_003_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0913	004	0	1	01	01	H0913_004_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0913	004	0	1	01	01	H0913_004_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H0913	004	0	1	01	01	H0913_004_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0913	004	0	1	01	01	H0913_004_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0913	005	0	1	01	01	H0913_005_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H0913	005	0	1	01	01	H0913_005_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H0913	005	0	1	01	01	H0913_005_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0913	005	0	1	01	01	H0913_005_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0967	001	0	1	04	01	H0967_001_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H0967	001	0	1	04	01	H0967_001_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H0967	001	0	1	04	01	H0967_001_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H0967	001	0	1	04	01	H0967_001_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H0979	005	0	1	09	04	H0979_005_0	11	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0979	005	0	1	09	04	H0979_005_0	11	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	72.00	216.00								72.00		72.00	216.00								72.00
H0979	005	0	1	09	04	H0979_005_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H0979	005	0	1	09	04	H0979_005_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		42.00	126.00								42.00
H0979	007	0	1	09	04	H0979_007_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H0979	007	0	1	09	04	H0979_007_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H0979	007	0	1	09	04	H0979_007_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0979	007	0	1	09	04	H0979_007_0	9	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	65.00	195.00								65.00		65.00	195.00								65.00
H0979	022	0	1	09	04	H0979_022_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H0979	022	0	1	09	04	H0979_022_0	11	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H0979	022	0	1	09	04	H0979_022_0	11	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	58.00	174.00								58.00		58.00	174.00								58.00
H0979	022	0	1	09	04	H0979_022_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H1013	011	0	1	01	01	H1013_011_0	7	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H1013	011	0	1	01	01	H1013_011_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1013	011	0	1	01	01	H1013_011_0	7	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	011	0	1	01	01	H1013_011_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H1013	011	0	1	01	01	H1013_011_0	7	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1013	011	0	1	01	01	H1013_011_0	7	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	011	0	1	01	01	H1013_011_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	011	0	1	01	01	H1013_011_0	7	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1013	021	0	1	01	01	H1013_021_0	8	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H1013	021	0	1	01	01	H1013_021_0	8	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	021	0	1	01	01	H1013_021_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1013	021	0	1	01	01	H1013_021_0	8	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1013	021	0	1	01	01	H1013_021_0	8	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	021	0	1	01	01	H1013_021_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00		20.00	40.00								20.00
H1013	021	0	1	01	01	H1013_021_0	8	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H1013	021	0	1	01	01	H1013_021_0	8	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1013	024	0	1	01	01	H1013_024_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00											77.00
H1013	024	0	1	01	01	H1013_024_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1013	024	0	1	01	01	H1013_024_0	6	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1013	024	0	1	01	01	H1013_024_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1013	024	0	1	01	01	H1013_024_0	6	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	024	0	1	01	01	H1013_024_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H1013	024	0	1	01	01	H1013_024_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H1013	024	0	1	01	01	H1013_024_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	028	0	1	01	01	H1013_028_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1013	028	0	1	01	01	H1013_028_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1013	028	0	1	01	01	H1013_028_0	6	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1013	028	0	1	01	01	H1013_028_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H1013	028	0	1	01	01	H1013_028_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	028	0	1	01	01	H1013_028_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1013	028	0	1	01	01	H1013_028_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H1013	028	0	1	01	01	H1013_028_0	6	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1016	001	0	1	01	01	H1016_001_0	9	2	4	1	Preferred Brand Name	000001	1	2				Preferred Brand Name	111000000010010000000	30	90								30										90	31	Preferred Brand Name	1	2	Preferred Brand Name																						Preferred Brand Name	0.00	0.00								0.00			0.00								0.00
H1016	001	0	1	01	01	H1016_001_0	9	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H1016	001	0	1	01	01	H1016_001_0	9	3	4	3	Non-Preferred Brand Name	100000	1	2	2			Non-Preferred Brand Name																							Non-Preferred Brand Name			Non-Preferred Brand Name																						Non-Preferred Brand Name																					
H1016	001	0	1	01	01	H1016_001_0	9	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H1016	001	0	1	01	01	H1016_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H1016	001	0	1	01	01	H1016_001_0	9	3	4	1	Non-Preferred Brand Name	100000	1	2				Non-Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non-Preferred Brand Name	1	2	Non-Preferred Brand Name																						Non-Preferred Brand Name	35.00	105.00								35.00			105.00								35.00
H1016	001	0	1	01	01	H1016_001_0	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1016	001	0	1	01	01	H1016_001_0	9	2	4	3	Preferred Brand Name	000001	1	2	2			Preferred Brand Name																							Preferred Brand Name			Preferred Brand Name																						Preferred Brand Name																					
H1016	002	0	1	01	01	H1016_002_0	11	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H1016	002	0	1	01	01	H1016_002_0	11	3	4	3	Non-Preferred Brand Name	100000	1	2	2			Non-Preferred Brand Name																							Non-Preferred Brand Name			Non-Preferred Brand Name																						Non-Preferred Brand Name																					
H1016	002	0	1	01	01	H1016_002_0	11	2	4	3	Preferred Brand Name	000001	1	2	2			Preferred Brand Name																							Preferred Brand Name			Preferred Brand Name																						Preferred Brand Name																					
H1016	002	0	1	01	01	H1016_002_0	11	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00
H1016	002	0	1	01	01	H1016_002_0	11	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1016	002	0	1	01	01	H1016_002_0	11	3	4	1	Non-Preferred Brand Name	100000	1	2				Non-Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non-Preferred Brand Name	1	2	Non-Preferred Brand Name																						Non-Preferred Brand Name	70.00	210.00								70.00			210.00								70.00
H1016	002	0	1	01	01	H1016_002_0	11	2	4	1	Preferred Brand Name	000001	1	2				Preferred Brand Name	111000000010010000000	30	90								30										90	31	Preferred Brand Name	1	2	Preferred Brand Name																						Preferred Brand Name	25.00	75.00								25.00			75.00								25.00
H1016	002	0	1	01	01	H1016_002_0	11	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	7.00	21.00								7.00			21.00								7.00
H1016	017	0	2	01	01	H1016_017_0	10	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H1016	017	0	2	01	01	H1016_017_0	10	3	4	1	Non-Preferred Brand Name	100000	1	2				Non-Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non-Preferred Brand Name	1	2	Non-Preferred Brand Name																						Non-Preferred Brand Name	70.00	210.00								70.00			210.00								70.00
H1016	017	0	2	01	01	H1016_017_0	10	2	4	1	Preferred Brand Name	000001	1	2				Preferred Brand Name	111000000010010000000	30	90								30										90	31	Preferred Brand Name	1	2	Preferred Brand Name																						Preferred Brand Name	25.00	75.00								25.00			75.00								25.00
H1016	017	0	2	01	01	H1016_017_0	10	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	7.00	21.00								7.00			21.00								7.00
H1016	017	0	2	01	01	H1016_017_0	10	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1016	017	0	2	01	01	H1016_017_0	10	3	4	3	Non-Preferred Brand Name	100000	1	2	2			Non-Preferred Brand Name																							Non-Preferred Brand Name			Non-Preferred Brand Name																						Non-Preferred Brand Name																					
H1016	017	0	2	01	01	H1016_017_0	10	2	4	3	Preferred Brand Name	000001	1	2	2			Preferred Brand Name																							Preferred Brand Name			Preferred Brand Name																						Preferred Brand Name																					
H1016	017	0	2	01	01	H1016_017_0	10	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00
H1019	001	0	1	01	01	H1019_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	001	0	1	01	01	H1019_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	001	0	1	01	01	H1019_001_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	001	0	1	01	01	H1019_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	001	0	1	01	01	H1019_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	001	0	1	01	01	H1019_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	001	0	1	01	01	H1019_001_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	001	0	1	01	01	H1019_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	002	0	1	01	01	H1019_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	002	0	1	01	01	H1019_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	002	0	1	01	01	H1019_002_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	002	0	1	01	01	H1019_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	002	0	1	01	01	H1019_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	002	0	1	01	01	H1019_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	002	0	1	01	01	H1019_002_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	002	0	1	01	01	H1019_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	004	0	1	01	01	H1019_004_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	1	Other (Gen/Brand)	25	25								25		25	25								25	Other (Gen/Brand)																					
H1019	004	0	1	01	01	H1019_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
H1019	004	0	1	01	01	H1019_004_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	004	0	1	01	01	H1019_004_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25		25	25								25	Non-Preferred Brand																					
H1019	004	0	1	01	01	H1019_004_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
H1019	004	0	1	01	01	H1019_004_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	1	Other (Gen/Brand)	25	25								25		25	25								25	Other (Gen/Brand)																					
H1019	004	0	1	01	01	H1019_004_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	004	0	1	01	01	H1019_004_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25		25	25								25	Non-Preferred Brand																					
H1019	005	0	1	01	01	H1019_005_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	005	0	1	01	01	H1019_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	005	0	1	01	01	H1019_005_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	005	0	1	01	01	H1019_005_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	005	0	1	01	01	H1019_005_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	005	0	1	01	01	H1019_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	005	0	1	01	01	H1019_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	005	0	1	01	01	H1019_005_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	006	0	1	01	01	H1019_006_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	006	0	1	01	01	H1019_006_0	2	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	006	0	1	01	01	H1019_006_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	006	0	1	01	01	H1019_006_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	006	0	1	01	01	H1019_006_0	2	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	006	0	1	01	01	H1019_006_0	2	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	006	0	1	01	01	H1019_006_0	2	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	006	0	1	01	01	H1019_006_0	2	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	010	0	1	01	01	H1019_010_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	010	0	1	01	01	H1019_010_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	010	0	1	01	01	H1019_010_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	010	0	1	01	01	H1019_010_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	010	0	1	01	01	H1019_010_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	010	0	1	01	01	H1019_010_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	010	0	1	01	01	H1019_010_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	010	0	1	01	01	H1019_010_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	011	0	1	01	01	H1019_011_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		75.00	187.50								75.00
H1019	011	0	1	01	01	H1019_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	011	0	1	01	01	H1019_011_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	011	0	1	01	01	H1019_011_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	011	0	1	01	01	H1019_011_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	011	0	1	01	01	H1019_011_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		75.00	187.50								75.00
H1019	011	0	1	01	01	H1019_011_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	011	0	1	01	01	H1019_011_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	014	0	1	01	01	H1019_014_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	014	0	1	01	01	H1019_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	014	0	1	01	01	H1019_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	014	0	1	01	01	H1019_014_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	014	0	1	01	01	H1019_014_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	014	0	1	01	01	H1019_014_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	014	0	1	01	01	H1019_014_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	014	0	1	01	01	H1019_014_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	023	0	1	01	01	H1019_023_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	023	0	1	01	01	H1019_023_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	023	0	1	01	01	H1019_023_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	023	0	1	01	01	H1019_023_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	023	0	1	01	01	H1019_023_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	023	0	1	01	01	H1019_023_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	023	0	1	01	01	H1019_023_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	023	0	1	01	01	H1019_023_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	024	0	1	01	01	H1019_024_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	024	0	1	01	01	H1019_024_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	024	0	1	01	01	H1019_024_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	024	0	1	01	01	H1019_024_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	024	0	1	01	01	H1019_024_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	024	0	1	01	01	H1019_024_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	024	0	1	01	01	H1019_024_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	024	0	1	01	01	H1019_024_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	025	0	1	01	01	H1019_025_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	025	0	1	01	01	H1019_025_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	025	0	1	01	01	H1019_025_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	025	0	1	01	01	H1019_025_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	025	0	1	01	01	H1019_025_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	025	0	1	01	01	H1019_025_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	025	0	1	01	01	H1019_025_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	025	0	1	01	01	H1019_025_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	026	0	1	01	01	H1019_026_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	026	0	1	01	01	H1019_026_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	026	0	1	01	01	H1019_026_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	026	0	1	01	01	H1019_026_0	4	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	026	0	1	01	01	H1019_026_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	026	0	1	01	01	H1019_026_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	026	0	1	01	01	H1019_026_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	026	0	1	01	01	H1019_026_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	027	0	1	01	01	H1019_027_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	027	0	1	01	01	H1019_027_0	4	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	027	0	1	01	01	H1019_027_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	027	0	1	01	01	H1019_027_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	027	0	1	01	01	H1019_027_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	027	0	1	01	01	H1019_027_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	027	0	1	01	01	H1019_027_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	027	0	1	01	01	H1019_027_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	028	0	1	01	01	H1019_028_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	028	0	1	01	01	H1019_028_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	028	0	1	01	01	H1019_028_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	028	0	1	01	01	H1019_028_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	028	0	1	01	01	H1019_028_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	028	0	1	01	01	H1019_028_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H1019	028	0	1	01	01	H1019_028_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H1019	028	0	1	01	01	H1019_028_0	4	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	029	0	1	01	01	H1019_029_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	029	0	1	01	01	H1019_029_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	029	0	1	01	01	H1019_029_0	4	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	029	0	1	01	01	H1019_029_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	029	0	1	01	01	H1019_029_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	029	0	1	01	01	H1019_029_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	029	0	1	01	01	H1019_029_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	029	0	1	01	01	H1019_029_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	030	0	1	01	01	H1019_030_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	030	0	1	01	01	H1019_030_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	030	0	1	01	01	H1019_030_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	030	0	1	01	01	H1019_030_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	030	0	1	01	01	H1019_030_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	030	0	1	01	01	H1019_030_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	030	0	1	01	01	H1019_030_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	030	0	1	01	01	H1019_030_0	6	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	032	0	1	01	01	H1019_032_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	032	0	1	01	01	H1019_032_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	032	0	1	01	01	H1019_032_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	032	0	1	01	01	H1019_032_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	032	0	1	01	01	H1019_032_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	032	0	1	01	01	H1019_032_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	032	0	1	01	01	H1019_032_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	032	0	1	01	01	H1019_032_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	033	0	1	01	01	H1019_033_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	033	0	1	01	01	H1019_033_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	033	0	1	01	01	H1019_033_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	033	0	1	01	01	H1019_033_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	033	0	1	01	01	H1019_033_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	033	0	1	01	01	H1019_033_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	25.00								10.00
H1019	033	0	1	01	01	H1019_033_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	033	0	1	01	01	H1019_033_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
H1019	035	0	1	01	01	H1019_035_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	035	0	1	01	01	H1019_035_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	035	0	1	01	01	H1019_035_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	035	0	1	01	01	H1019_035_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	035	0	1	01	01	H1019_035_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	035	0	1	01	01	H1019_035_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	035	0	1	01	01	H1019_035_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	035	0	1	01	01	H1019_035_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	036	0	1	01	01	H1019_036_0	5	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	036	0	1	01	01	H1019_036_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	036	0	1	01	01	H1019_036_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	036	0	1	01	01	H1019_036_0	5	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	036	0	1	01	01	H1019_036_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	036	0	1	01	01	H1019_036_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	036	0	1	01	01	H1019_036_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	036	0	1	01	01	H1019_036_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00		15.00	37.50								15.00
H1019	037	0	1	01	01	H1019_037_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	037	0	1	01	01	H1019_037_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	037	0	1	01	01	H1019_037_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	037	0	1	01	01	H1019_037_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	037	0	1	01	01	H1019_037_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	037	0	1	01	01	H1019_037_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	037	0	1	01	01	H1019_037_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	037	0	1	01	01	H1019_037_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	038	0	1	01	01	H1019_038_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	038	0	1	01	01	H1019_038_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	038	0	1	01	01	H1019_038_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	038	0	1	01	01	H1019_038_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	038	0	1	01	01	H1019_038_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H1019	038	0	1	01	01	H1019_038_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00		0.00	0.00								0.00
H1019	038	0	1	01	01	H1019_038_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	175.00								70.00
H1019	038	0	1	01	01	H1019_038_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	040	0	1	01	01	H1019_040_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	040	0	1	01	01	H1019_040_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	040	0	1	01	01	H1019_040_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	040	0	1	01	01	H1019_040_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	040	0	1	01	01	H1019_040_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	040	0	1	01	01	H1019_040_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	040	0	1	01	01	H1019_040_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	040	0	1	01	01	H1019_040_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	041	0	1	01	01	H1019_041_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	041	0	1	01	01	H1019_041_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	041	0	1	01	01	H1019_041_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	041	0	1	01	01	H1019_041_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	041	0	1	01	01	H1019_041_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	041	0	1	01	01	H1019_041_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	125.00								50.00
H1019	041	0	1	01	01	H1019_041_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1019	041	0	1	01	01	H1019_041_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	043	0	1	01	01	H1019_043_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1019	043	0	1	01	01	H1019_043_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		75.00	187.50								75.00
H1019	043	0	1	01	01	H1019_043_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	043	0	1	01	01	H1019_043_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	043	0	1	01	01	H1019_043_0	6	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H1019	043	0	1	01	01	H1019_043_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00
H1019	043	0	1	01	01	H1019_043_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		75.00	187.50								75.00
H1019	043	0	1	01	01	H1019_043_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010100000000	30									30		30									34	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H1026	001	0	1	01	01	H1026_001_0	7	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	95.00	285.00	190.00							95.00		95.00	190.00	190.00							95.00
H1026	001	0	1	01	01	H1026_001_0	7	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H1026	001	0	1	01	01	H1026_001_0	7	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00
H1026	001	0	1	01	01	H1026_001_0	7	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H1026	001	0	1	01	01	H1026_001_0	7	1	4	3	Tier 1 - Covered Generic	010000	3	2	1		1	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00
H1026	001	0	1	01	01	H1026_001_0	7	2	4	3	Tier 2 - Covered Preferred Brand	000001	1	2	2			Tier 2 - Covered Preferred Brand																							Tier 2 - Covered Preferred Brand			Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand																					
H1026	001	0	1	01	01	H1026_001_0	7	3	4	3	Tier 3 - Covered Brand	100000	1	2	2			Tier 3 - Covered Brand																							Tier 3 - Covered Brand			Tier 3 - Covered Brand																						Tier 3 - Covered Brand																					
H1026	001	0	1	01	01	H1026_001_0	7	4	4	3	Tier S - Covered Specialty	110001	1	1	2			Tier S - Covered Specialty																							Tier S - Covered Specialty			Tier S - Covered Specialty																						Tier S - Covered Specialty																					
H1026	033	0	1	01	01	H1026_033_0	7	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H1026	033	0	1	01	01	H1026_033_0	7	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H1026	033	0	1	01	01	H1026_033_0	7	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H1026	033	0	1	01	01	H1026_033_0	7	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H1026	035	0	1	01	01	H1026_035_0	6	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H1026	035	0	1	01	01	H1026_035_0	6	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H1026	035	0	1	01	01	H1026_035_0	6	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H1026	035	0	1	01	01	H1026_035_0	6	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H1026	038	0	1	01	01	H1026_038_0	7	1	4	3	Tier 1 - Covered Generic	010000	3	2	1		1	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00
H1026	038	0	1	01	01	H1026_038_0	7	2	4	3	Tier 2 - Covered Preferred Brand	000001	1	2	2			Tier 2 - Covered Preferred Brand																							Tier 2 - Covered Preferred Brand			Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand																					
H1026	038	0	1	01	01	H1026_038_0	7	3	4	3	Tier 3 - Covered Brand	100000	1	2	2			Tier 3 - Covered Brand																							Tier 3 - Covered Brand			Tier 3 - Covered Brand																						Tier 3 - Covered Brand																					
H1026	038	0	1	01	01	H1026_038_0	7	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H1026	038	0	1	01	01	H1026_038_0	7	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	95.00	285.00	190.00							95.00		95.00	190.00	190.00							95.00
H1026	038	0	1	01	01	H1026_038_0	7	4	4	3	Tier S - Covered Specialty	110001	1	1	2			Tier S - Covered Specialty																							Tier S - Covered Specialty			Tier S - Covered Specialty																						Tier S - Covered Specialty																					
H1026	038	0	1	01	01	H1026_038_0	7	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00
H1026	038	0	1	01	01	H1026_038_0	7	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H1032	002	0	1	02	01	H1032_002_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	002	0	1	02	01	H1032_002_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00
H1032	002	0	1	02	01	H1032_002_0	11	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	002	0	1	02	01	H1032_002_0	11	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	002	0	1	02	01	H1032_002_0	11	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	002	0	1	02	01	H1032_002_0	11	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	002	0	1	02	01	H1032_002_0	11	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	002	0	1	02	01	H1032_002_0	11	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H1032	008	0	1	02	01	H1032_008_0	7	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	008	0	1	02	01	H1032_008_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	008	0	1	02	01	H1032_008_0	7	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	008	0	1	02	01	H1032_008_0	7	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	008	0	1	02	01	H1032_008_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	008	0	1	02	01	H1032_008_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00			60.00								20.00
H1032	008	0	1	02	01	H1032_008_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	0.00	0.00								0.00			0.00								0.00
H1032	008	0	1	02	01	H1032_008_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	010	0	1	02	01	H1032_010_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	010	0	1	02	01	H1032_010_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	010	0	1	02	01	H1032_010_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	010	0	1	02	01	H1032_010_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	010	0	1	02	01	H1032_010_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	010	0	1	02	01	H1032_010_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	010	0	1	02	01	H1032_010_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			75.00								25.00
H1032	010	0	1	02	01	H1032_010_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	012	0	1	02	01	H1032_012_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	012	0	1	02	01	H1032_012_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	012	0	1	02	01	H1032_012_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	012	0	1	02	01	H1032_012_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			45.00								15.00
H1032	012	0	1	02	01	H1032_012_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			150.00								50.00
H1032	012	0	1	02	01	H1032_012_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	012	0	1	02	01	H1032_012_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	012	0	1	02	01	H1032_012_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	014	0	1	02	01	H1032_014_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	014	0	1	02	01	H1032_014_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	014	0	1	02	01	H1032_014_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	014	0	1	02	01	H1032_014_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			45.00								15.00
H1032	014	0	1	02	01	H1032_014_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00			120.00								40.00
H1032	014	0	1	02	01	H1032_014_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	014	0	1	02	01	H1032_014_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	014	0	1	02	01	H1032_014_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	019	0	1	02	01	H1032_019_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	019	0	1	02	01	H1032_019_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	019	0	1	02	01	H1032_019_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	019	0	1	02	01	H1032_019_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	019	0	1	02	01	H1032_019_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	019	0	1	02	01	H1032_019_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			150.00								50.00
H1032	019	0	1	02	01	H1032_019_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			45.00								15.00
H1032	019	0	1	02	01	H1032_019_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	025	0	1	02	01	H1032_025_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	025	0	1	02	01	H1032_025_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	025	0	1	02	01	H1032_025_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	025	0	1	02	01	H1032_025_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	028	0	1	02	01	H1032_028_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	028	0	1	02	01	H1032_028_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	028	0	1	02	01	H1032_028_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	028	0	1	02	01	H1032_028_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	028	0	1	02	01	H1032_028_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	028	0	1	02	01	H1032_028_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	028	0	1	02	01	H1032_028_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	028	0	1	02	01	H1032_028_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	031	0	1	02	01	H1032_031_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	031	0	1	02	01	H1032_031_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	031	0	1	02	01	H1032_031_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	031	0	1	02	01	H1032_031_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	032	0	1	02	01	H1032_032_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	032	0	1	02	01	H1032_032_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	032	0	1	02	01	H1032_032_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H1032	032	0	1	02	01	H1032_032_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	033	0	1	02	01	H1032_033_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	033	0	1	02	01	H1032_033_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	033	0	1	02	01	H1032_033_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	033	0	1	02	01	H1032_033_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	033	0	1	02	01	H1032_033_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	033	0	1	02	01	H1032_033_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	033	0	1	02	01	H1032_033_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	033	0	1	02	01	H1032_033_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	035	0	1	02	01	H1032_035_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	035	0	1	02	01	H1032_035_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	035	0	1	02	01	H1032_035_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00
H1032	035	0	1	02	01	H1032_035_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	035	0	1	02	01	H1032_035_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	035	0	1	02	01	H1032_035_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	035	0	1	02	01	H1032_035_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	035	0	1	02	01	H1032_035_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	040	0	1	02	01	H1032_040_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	040	0	1	02	01	H1032_040_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			75.00								25.00
H1032	040	0	1	02	01	H1032_040_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			150.00								50.00
H1032	040	0	1	02	01	H1032_040_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	043	0	1	02	01	H1032_043_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	043	0	1	02	01	H1032_043_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	043	0	1	02	01	H1032_043_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	043	0	1	02	01	H1032_043_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	044	0	1	02	01	H1032_044_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	044	0	1	02	01	H1032_044_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	044	0	1	02	01	H1032_044_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	044	0	1	02	01	H1032_044_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	060	0	1	02	01	H1032_060_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	060	0	1	02	01	H1032_060_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	060	0	1	02	01	H1032_060_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	060	0	1	02	01	H1032_060_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	061	0	1	02	01	H1032_061_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	061	0	1	02	01	H1032_061_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00
H1032	061	0	1	02	01	H1032_061_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	061	0	1	02	01	H1032_061_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	064	0	1	02	01	H1032_064_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	064	0	1	02	01	H1032_064_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
H1032	064	0	1	02	01	H1032_064_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1032	064	0	1	02	01	H1032_064_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	065	0	1	02	01	H1032_065_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	065	0	1	02	01	H1032_065_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	065	0	1	02	01	H1032_065_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	065	0	1	02	01	H1032_065_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	066	0	1	02	01	H1032_066_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	066	0	1	02	01	H1032_066_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	066	0	1	02	01	H1032_066_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	066	0	1	02	01	H1032_066_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	069	0	1	02	01	H1032_069_0	7	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	069	0	1	02	01	H1032_069_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	069	0	1	02	01	H1032_069_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	069	0	1	02	01	H1032_069_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	069	0	1	02	01	H1032_069_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			150.00								50.00
H1032	069	0	1	02	01	H1032_069_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			45.00								15.00
H1032	069	0	1	02	01	H1032_069_0	7	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	069	0	1	02	01	H1032_069_0	7	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	073	0	1	02	01	H1032_073_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	073	0	1	02	01	H1032_073_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	073	0	1	02	01	H1032_073_0	11	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00
H1032	073	0	1	02	01	H1032_073_0	11	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	073	0	1	02	01	H1032_073_0	11	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	073	0	1	02	01	H1032_073_0	11	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	073	0	1	02	01	H1032_073_0	11	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	073	0	1	02	01	H1032_073_0	11	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	079	0	1	02	01	H1032_079_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	079	0	1	02	01	H1032_079_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	079	0	1	02	01	H1032_079_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	079	0	1	02	01	H1032_079_0	6	1	4	3	Tier 1	010000	3	2	2			Tier 1																							Tier 1			Tier 1																						Tier 1																					
H1032	079	0	1	02	01	H1032_079_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	079	0	1	02	01	H1032_079_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	079	0	1	02	01	H1032_079_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	079	0	1	02	01	H1032_079_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	085	0	1	01	01	H1032_085_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00
H1032	085	0	1	01	01	H1032_085_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
H1032	085	0	1	01	01	H1032_085_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	085	0	1	01	01	H1032_085_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	086	0	1	01	01	H1032_086_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	086	0	1	01	01	H1032_086_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	086	0	1	01	01	H1032_086_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	086	0	1	01	01	H1032_086_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	088	0	1	01	01	H1032_088_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	088	0	1	01	01	H1032_088_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	088	0	1	01	01	H1032_088_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	088	0	1	01	01	H1032_088_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	089	0	1	01	01	H1032_089_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	089	0	1	01	01	H1032_089_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	089	0	1	01	01	H1032_089_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	089	0	1	01	01	H1032_089_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	091	0	1	02	01	H1032_091_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	091	0	1	02	01	H1032_091_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	091	0	1	02	01	H1032_091_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	091	0	1	02	01	H1032_091_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	091	0	1	02	01	H1032_091_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	091	0	1	02	01	H1032_091_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	091	0	1	02	01	H1032_091_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	091	0	1	02	01	H1032_091_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	097	0	1	02	01	H1032_097_0	9	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	097	0	1	02	01	H1032_097_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	097	0	1	02	01	H1032_097_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	097	0	1	02	01	H1032_097_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	098	0	1	02	01	H1032_098_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	098	0	1	02	01	H1032_098_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	098	0	1	02	01	H1032_098_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	098	0	1	02	01	H1032_098_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	101	0	1	02	01	H1032_101_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	101	0	1	02	01	H1032_101_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	101	0	1	02	01	H1032_101_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	101	0	1	02	01	H1032_101_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	102	0	1	02	01	H1032_102_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
H1032	102	0	1	02	01	H1032_102_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	102	0	1	02	01	H1032_102_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1032	102	0	1	02	01	H1032_102_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	104	0	1	02	01	H1032_104_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	104	0	1	02	01	H1032_104_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	104	0	1	02	01	H1032_104_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	104	0	1	02	01	H1032_104_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	106	0	1	02	01	H1032_106_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	106	0	1	02	01	H1032_106_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	106	0	1	02	01	H1032_106_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	106	0	1	02	01	H1032_106_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	107	0	1	02	01	H1032_107_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	107	0	1	02	01	H1032_107_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	107	0	1	02	01	H1032_107_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
H1032	107	0	1	02	01	H1032_107_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	113	0	1	02	01	H1032_113_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	113	0	1	02	01	H1032_113_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	113	0	1	02	01	H1032_113_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	113	0	1	02	01	H1032_113_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	122	0	1	01	01	H1032_122_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
H1032	122	0	1	01	01	H1032_122_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	122	0	1	01	01	H1032_122_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	122	0	1	01	01	H1032_122_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00
H1032	123	0	1	01	01	H1032_123_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	123	0	1	01	01	H1032_123_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	123	0	1	01	01	H1032_123_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	123	0	1	01	01	H1032_123_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	124	0	1	01	01	H1032_124_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	124	0	1	01	01	H1032_124_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	124	0	1	01	01	H1032_124_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	124	0	1	01	01	H1032_124_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	125	0	1	01	01	H1032_125_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1032	125	0	1	01	01	H1032_125_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	125	0	1	01	01	H1032_125_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	125	0	1	01	01	H1032_125_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00
H1032	126	0	1	02	01	H1032_126_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	126	0	1	02	01	H1032_126_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	126	0	1	02	01	H1032_126_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	126	0	1	02	01	H1032_126_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	127	0	1	01	01	H1032_127_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1032	127	0	1	01	01	H1032_127_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
H1032	127	0	1	01	01	H1032_127_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	127	0	1	01	01	H1032_127_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	128	0	1	01	01	H1032_128_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	128	0	1	01	01	H1032_128_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	128	0	1	01	01	H1032_128_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	128	0	1	01	01	H1032_128_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	130	0	1	01	01	H1032_130_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	130	0	1	01	01	H1032_130_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	130	0	1	01	01	H1032_130_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	130	0	1	01	01	H1032_130_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	131	0	1	02	01	H1032_131_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	131	0	1	02	01	H1032_131_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	131	0	1	02	01	H1032_131_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	131	0	1	02	01	H1032_131_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	132	0	1	02	01	H1032_132_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	132	0	1	02	01	H1032_132_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	132	0	1	02	01	H1032_132_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	132	0	1	02	01	H1032_132_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	132	0	1	02	01	H1032_132_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	132	0	1	02	01	H1032_132_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	132	0	1	02	01	H1032_132_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	132	0	1	02	01	H1032_132_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	133	0	1	02	01	H1032_133_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	133	0	1	02	01	H1032_133_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	133	0	1	02	01	H1032_133_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	133	0	1	02	01	H1032_133_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	133	0	1	02	01	H1032_133_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	133	0	1	02	01	H1032_133_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	133	0	1	02	01	H1032_133_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H1032	133	0	1	02	01	H1032_133_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1032	136	0	1	02	01	H1032_136_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	136	0	1	02	01	H1032_136_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	136	0	1	02	01	H1032_136_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	136	0	1	02	01	H1032_136_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	138	0	1	01	01	H1032_138_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1032	138	0	1	01	01	H1032_138_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00
H1032	138	0	1	01	01	H1032_138_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	138	0	1	01	01	H1032_138_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	144	0	1	02	01	H1032_144_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	144	0	1	02	01	H1032_144_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	144	0	1	02	01	H1032_144_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1032	144	0	1	02	01	H1032_144_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	144	0	1	02	01	H1032_144_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	144	0	1	02	01	H1032_144_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	144	0	1	02	01	H1032_144_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	144	0	1	02	01	H1032_144_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	145	0	1	02	01	H1032_145_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	145	0	1	02	01	H1032_145_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	145	0	1	02	01	H1032_145_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H1032	145	0	1	02	01	H1032_145_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1032	146	0	1	02	01	H1032_146_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	146	0	1	02	01	H1032_146_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	146	0	1	02	01	H1032_146_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00
H1032	146	0	1	02	01	H1032_146_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			75.00								25.00
H1032	146	0	1	02	01	H1032_146_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	146	0	1	02	01	H1032_146_0	6	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	146	0	1	02	01	H1032_146_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	146	0	1	02	01	H1032_146_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	148	0	1	01	01	H1032_148_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	148	0	1	01	01	H1032_148_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	41.00	123.00								41.00			123.00								41.00
H1032	148	0	1	01	01	H1032_148_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1032	148	0	1	01	01	H1032_148_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	152	0	1	02	01	H1032_152_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	152	0	1	02	01	H1032_152_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	152	0	1	02	01	H1032_152_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	152	0	1	02	01	H1032_152_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	153	0	1	02	01	H1032_153_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	153	0	1	02	01	H1032_153_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	153	0	1	02	01	H1032_153_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	153	0	1	02	01	H1032_153_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	162	0	1	02	01	H1032_162_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	162	0	1	02	01	H1032_162_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	162	0	1	02	01	H1032_162_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1032	162	0	1	02	01	H1032_162_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	163	0	1	01	01	H1032_163_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	163	0	1	01	01	H1032_163_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1032	163	0	1	01	01	H1032_163_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1032	163	0	1	01	01	H1032_163_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	91.00	273.00								91.00			273.00								91.00
H1032	164	0	1	02	01	H1032_164_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	164	0	1	02	01	H1032_164_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	39.00	117.00								39.00			117.00								39.00
H1032	164	0	1	02	01	H1032_164_0	6	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	0.00	0.00								0.00			0.00								0.00
H1032	164	0	1	02	01	H1032_164_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	166	0	1	02	01	H1032_166_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	166	0	1	02	01	H1032_166_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	5.00	15.00								5.00			15.00								5.00
H1032	166	0	1	02	01	H1032_166_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1032	166	0	1	02	01	H1032_166_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	166	0	1	02	01	H1032_166_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	166	0	1	02	01	H1032_166_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	166	0	1	02	01	H1032_166_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	166	0	1	02	01	H1032_166_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00			120.00								40.00
H1032	168	0	1	02	01	H1032_168_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	168	0	1	02	01	H1032_168_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1032	168	0	1	02	01	H1032_168_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1032	168	0	1	02	01	H1032_168_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1032	168	0	1	02	01	H1032_168_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1032	168	0	1	02	01	H1032_168_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00
H1032	168	0	1	02	01	H1032_168_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1032	168	0	1	02	01	H1032_168_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1035	002	0	1	02	01	H1035_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	100011011010010000000				31	93		31	93		31										93	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				4.00	12.00		10.00	30.00		10.00			9.00								10.00
H1035	002	0	1	02	01	H1035_002_0	6	7	4	3	Enhanced Medicare	010000	2	2	1		1	Enhanced Medicare	100011010010010000000				31	93		31			31										93	31	Enhanced Medicare	2	2	Enhanced Medicare																						Enhanced Medicare				10.00	30.00		15.00			15.00			27.00								15.00
H1035	002	0	1	02	01	H1035_002_0	6	6	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1035	002	0	1	02	01	H1035_002_0	6	5	4	3	Injectables	010010	1	2	2			Injectables																							Injectables			Injectables																						Injectables																					
H1035	002	0	1	02	01	H1035_002_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1035	002	0	1	02	01	H1035_002_0	6	2	4	1	Non-Preferred Generic	000100	1	2				Non-Preferred Generic	100011011010010000000				31	93		31	93		31										93	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				6.00	18.00		10.00	30.00		10.00			15.00								10.00
H1035	002	0	1	02	01	H1035_002_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1035	002	0	1	02	01	H1035_002_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				31	93		31	93		31										93	31	Non-Preferred Brand	2	1	Non-Preferred Brand				50	50		75	75		75			50								75	Non-Preferred Brand																					
H1035	002	0	1	02	01	H1035_002_0	6	5	4	1	Injectables	010010	1	2				Injectables	100011010010010000000				31	93		31			31										93	31	Injectables	2	1	Injectables				25	25		25			25			25								25	Injectables																					
H1035	002	0	1	02	01	H1035_002_0	6	6	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	100011010010010000000				31	93		31			31										93	31	Specialty Drugs	2	1	Specialty Drugs				33	33		33			33			33								33	Specialty Drugs																					
H1035	002	0	1	02	01	H1035_002_0	6	7	4	1	Enhanced Medicare	010000	2	2				Enhanced Medicare	100011010010010000000				31	93		31			31										93	31	Enhanced Medicare	2	2	Enhanced Medicare																						Enhanced Medicare				10.00	30.00		15.00			15.00			27.00								15.00
H1035	002	0	1	02	01	H1035_002_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	100011010010010000000				31	93		31			31										93	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				4.00	12.00		10.00			10.00			9.00								10.00
H1035	002	0	1	02	01	H1035_002_0	6	2	4	3	Non-Preferred Generic	000100	1	2	1		1	Non-Preferred Generic	100011010010010000000				31	93		31			31										93	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				6.00	18.00		10.00			10.00			15.00								10.00
H1035	002	0	1	02	01	H1035_002_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				31	93		31	93		31										93	31	Preferred Brand	2	1	Preferred Brand				25	25		50	50		50			25								50	Preferred Brand																					
H1035	006	0	1	02	01	H1035_006_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	100011011010010000000				31	93		31	93		31										93	31	Preferred Generic	2	1	Preferred Generic				20	20		30	30		30			20								30	Preferred Generic																					
H1035	006	0	1	02	01	H1035_006_0	7	6	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	100011010010010000000				31	93		31			31										93	31	Specialty Drugs	2	1	Specialty Drugs				29	29		29			29			29								29	Specialty Drugs																					
H1035	006	0	1	02	01	H1035_006_0	7	5	4	1	Injectables	010010	1	2				Injectables	100011010010010000000				31	93		31			31										93	31	Injectables	2	1	Injectables				25	25		25			25			25								25	Injectables																					
H1035	006	0	1	02	01	H1035_006_0	7	2	4	1	Non-Preferred Generic	000100	1	2				Non-Preferred Generic	100011011010010000000				31	93		31	93		31										93	31	Non-Preferred Generic	2	1	Non-Preferred Generic				20	20		30	30		30			20								30	Non-Preferred Generic																					
H1035	006	0	1	02	01	H1035_006_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				31	93		31	93		31										93	31	Preferred Brand	2	1	Preferred Brand				25	25		35	35		35			25								35	Preferred Brand																					
H1035	006	0	1	02	01	H1035_006_0	7	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				31	93		31	93		31										93	31	Non-Preferred Brand	2	1	Non-Preferred Brand				40	40		50	50		50			40								50	Non-Preferred Brand																					
H1036	011	0	1	01	01	H1036_011_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	011	0	1	01	01	H1036_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	011	0	1	01	01	H1036_011_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	011	0	1	01	01	H1036_011_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	011	0	1	01	01	H1036_011_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	011	0	1	01	01	H1036_011_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	011	0	1	01	01	H1036_011_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	011	0	1	01	01	H1036_011_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	025	0	1	01	01	H1036_025_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	025	0	1	01	01	H1036_025_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	025	0	1	01	01	H1036_025_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	034	0	1	01	01	H1036_034_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	034	0	1	01	01	H1036_034_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	034	0	1	01	01	H1036_034_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	034	0	1	01	01	H1036_034_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	034	0	1	01	01	H1036_034_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	034	0	1	01	01	H1036_034_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	034	0	1	01	01	H1036_034_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	034	0	1	01	01	H1036_034_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	035	0	1	01	01	H1036_035_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	035	0	1	01	01	H1036_035_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	035	0	1	01	01	H1036_035_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	035	0	1	01	01	H1036_035_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	035	0	1	01	01	H1036_035_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	035	0	1	01	01	H1036_035_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	035	0	1	01	01	H1036_035_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	035	0	1	01	01	H1036_035_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	037	0	1	01	01	H1036_037_0	4	1	4	1	Other (Gen/Brand)	010010	1	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	037	0	1	01	01	H1036_037_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	037	0	1	01	01	H1036_037_0	4	1	4	3	Other (Gen/Brand)	010010	1	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	037	0	1	01	01	H1036_037_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	037	0	1	01	01	H1036_037_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	037	0	1	01	01	H1036_037_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	037	0	1	01	01	H1036_037_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	037	0	1	01	01	H1036_037_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	040	0	1	01	01	H1036_040_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	040	0	1	01	01	H1036_040_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	040	0	1	01	01	H1036_040_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	040	0	1	01	01	H1036_040_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	040	0	1	01	01	H1036_040_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	040	0	1	01	01	H1036_040_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	040	0	1	01	01	H1036_040_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	040	0	1	01	01	H1036_040_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	044	0	1	01	01	H1036_044_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	044	0	1	01	01	H1036_044_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	044	0	1	01	01	H1036_044_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	044	0	1	01	01	H1036_044_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	044	0	1	01	01	H1036_044_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	044	0	1	01	01	H1036_044_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	044	0	1	01	01	H1036_044_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	044	0	1	01	01	H1036_044_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	047	0	1	01	01	H1036_047_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	047	0	1	01	01	H1036_047_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	047	0	1	01	01	H1036_047_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	047	0	1	01	01	H1036_047_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	047	0	1	01	01	H1036_047_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	047	0	1	01	01	H1036_047_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	047	0	1	01	01	H1036_047_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	047	0	1	01	01	H1036_047_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	052	0	1	01	01	H1036_052_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	052	0	1	01	01	H1036_052_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	052	0	1	01	01	H1036_052_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	052	0	1	01	01	H1036_052_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	052	0	1	01	01	H1036_052_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	052	0	1	01	01	H1036_052_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	052	0	1	01	01	H1036_052_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	052	0	1	01	01	H1036_052_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	2	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	2	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	054	0	1	01	01	H1036_054_0	2	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	054	0	1	01	01	H1036_054_0	2	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	2	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	054	0	1	01	01	H1036_054_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	062	0	1	01	01	H1036_062_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	062	0	1	01	01	H1036_062_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	062	0	1	01	01	H1036_062_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	062	0	1	01	01	H1036_062_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	062	0	1	01	01	H1036_062_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	062	0	1	01	01	H1036_062_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	062	0	1	01	01	H1036_062_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	062	0	1	01	01	H1036_062_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	065	0	1	01	01	H1036_065_0	2	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	065	0	1	01	01	H1036_065_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	065	0	1	01	01	H1036_065_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	065	0	1	01	01	H1036_065_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	065	0	1	01	01	H1036_065_0	2	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	065	0	1	01	01	H1036_065_0	2	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	065	0	1	01	01	H1036_065_0	2	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	065	0	1	01	01	H1036_065_0	2	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	067	0	1	01	01	H1036_067_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	067	0	1	01	01	H1036_067_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	067	0	1	01	01	H1036_067_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	067	0	1	01	01	H1036_067_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	067	0	1	01	01	H1036_067_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	067	0	1	01	01	H1036_067_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	067	0	1	01	01	H1036_067_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	067	0	1	01	01	H1036_067_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	068	0	1	01	01	H1036_068_0	4	1	4	1	Other (Gen/Brand)	010010	1	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	068	0	1	01	01	H1036_068_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	068	0	1	01	01	H1036_068_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	068	0	1	01	01	H1036_068_0	4	1	4	3	Other (Gen/Brand)	010010	1	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	068	0	1	01	01	H1036_068_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	068	0	1	01	01	H1036_068_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	068	0	1	01	01	H1036_068_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	068	0	1	01	01	H1036_068_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	074	0	1	01	01	H1036_074_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	074	0	1	01	01	H1036_074_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	074	0	1	01	01	H1036_074_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	074	0	1	01	01	H1036_074_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	074	0	1	01	01	H1036_074_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	074	0	1	01	01	H1036_074_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	074	0	1	01	01	H1036_074_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	074	0	1	01	01	H1036_074_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	077	0	1	01	01	H1036_077_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	077	0	1	01	01	H1036_077_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	077	0	1	01	01	H1036_077_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	077	0	1	01	01	H1036_077_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	077	0	1	01	01	H1036_077_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	077	0	1	01	01	H1036_077_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	077	0	1	01	01	H1036_077_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	077	0	1	01	01	H1036_077_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	081	0	1	01	01	H1036_081_0	4	1	4	1	Other (Gen/Brand)	010010	1	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	081	0	1	01	01	H1036_081_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	081	0	1	01	01	H1036_081_0	4	1	4	3	Other (Gen/Brand)	010010	1	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	081	0	1	01	01	H1036_081_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	081	0	1	01	01	H1036_081_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	081	0	1	01	01	H1036_081_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	081	0	1	01	01	H1036_081_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	081	0	1	01	01	H1036_081_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	100	0	1	01	01	H1036_100_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	100	0	1	01	01	H1036_100_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	100	0	1	01	01	H1036_100_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H1036	100	0	1	01	01	H1036_100_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	100	0	1	01	01	H1036_100_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	100	0	1	01	01	H1036_100_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	100	0	1	01	01	H1036_100_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H1036	100	0	1	01	01	H1036_100_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	102	0	1	01	01	H1036_102_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	102	0	1	01	01	H1036_102_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	102	0	1	01	01	H1036_102_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	102	0	1	01	01	H1036_102_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	102	0	1	01	01	H1036_102_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	102	0	1	01	01	H1036_102_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	102	0	1	01	01	H1036_102_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	102	0	1	01	01	H1036_102_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	103	0	1	01	01	H1036_103_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	103	0	1	01	01	H1036_103_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	103	0	1	01	01	H1036_103_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	103	0	1	01	01	H1036_103_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	103	0	1	01	01	H1036_103_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	103	0	1	01	01	H1036_103_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	103	0	1	01	01	H1036_103_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	103	0	1	01	01	H1036_103_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	104	0	1	01	01	H1036_104_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	104	0	1	01	01	H1036_104_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	104	0	1	01	01	H1036_104_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	104	0	1	01	01	H1036_104_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	104	0	1	01	01	H1036_104_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	104	0	1	01	01	H1036_104_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	104	0	1	01	01	H1036_104_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	104	0	1	01	01	H1036_104_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	105	0	1	01	01	H1036_105_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	105	0	1	01	01	H1036_105_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	105	0	1	01	01	H1036_105_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	105	0	1	01	01	H1036_105_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	105	0	1	01	01	H1036_105_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	105	0	1	01	01	H1036_105_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	105	0	1	01	01	H1036_105_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	105	0	1	01	01	H1036_105_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	106	0	1	01	01	H1036_106_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	106	0	1	01	01	H1036_106_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	106	0	1	01	01	H1036_106_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	106	0	1	01	01	H1036_106_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	106	0	1	01	01	H1036_106_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	106	0	1	01	01	H1036_106_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	106	0	1	01	01	H1036_106_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	106	0	1	01	01	H1036_106_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	108	0	1	01	01	H1036_108_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	108	0	1	01	01	H1036_108_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	108	0	1	01	01	H1036_108_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	108	0	1	01	01	H1036_108_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	108	0	1	01	01	H1036_108_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	108	0	1	01	01	H1036_108_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	108	0	1	01	01	H1036_108_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	108	0	1	01	01	H1036_108_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	109	0	1	01	01	H1036_109_0	6	1	4	1	Other (Gen/Brand)	010010	1	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	109	0	1	01	01	H1036_109_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	109	0	1	01	01	H1036_109_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	109	0	1	01	01	H1036_109_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	109	0	1	01	01	H1036_109_0	6	1	4	3	Other (Gen/Brand)	010010	1	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	109	0	1	01	01	H1036_109_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	109	0	1	01	01	H1036_109_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	109	0	1	01	01	H1036_109_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	110	0	1	01	01	H1036_110_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	110	0	1	01	01	H1036_110_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	110	0	1	01	01	H1036_110_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	110	0	1	01	01	H1036_110_0	4	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	110	0	1	01	01	H1036_110_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1036	110	0	1	01	01	H1036_110_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	110	0	1	01	01	H1036_110_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	110	0	1	01	01	H1036_110_0	4	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1036	114	0	1	01	01	H1036_114_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	114	0	1	01	01	H1036_114_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	114	0	1	01	01	H1036_114_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	114	0	1	01	01	H1036_114_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	114	0	1	01	01	H1036_114_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	114	0	1	01	01	H1036_114_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	114	0	1	01	01	H1036_114_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	114	0	1	01	01	H1036_114_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1036	115	0	1	01	01	H1036_115_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	115	0	1	01	01	H1036_115_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	115	0	1	01	01	H1036_115_0	6	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	115	0	1	01	01	H1036_115_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	115	0	1	01	01	H1036_115_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	115	0	1	01	01	H1036_115_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	115	0	1	01	01	H1036_115_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	115	0	1	01	01	H1036_115_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	116	0	1	01	01	H1036_116_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	116	0	1	01	01	H1036_116_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	116	0	1	01	01	H1036_116_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	116	0	1	01	01	H1036_116_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	116	0	1	01	01	H1036_116_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	116	0	1	01	01	H1036_116_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	116	0	1	01	01	H1036_116_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00
H1036	116	0	1	01	01	H1036_116_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	117	0	1	01	01	H1036_117_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	117	0	1	01	01	H1036_117_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	117	0	1	01	01	H1036_117_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	117	0	1	01	01	H1036_117_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	117	0	1	01	01	H1036_117_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	117	0	1	01	01	H1036_117_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	117	0	1	01	01	H1036_117_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	117	0	1	01	01	H1036_117_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	118	0	1	01	01	H1036_118_0	8	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	118	0	1	01	01	H1036_118_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	118	0	1	01	01	H1036_118_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	118	0	1	01	01	H1036_118_0	8	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1036	118	0	1	01	01	H1036_118_0	8	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	118	0	1	01	01	H1036_118_0	8	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	118	0	1	01	01	H1036_118_0	8	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	118	0	1	01	01	H1036_118_0	8	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	121	0	1	01	01	H1036_121_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	121	0	1	01	01	H1036_121_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	121	0	1	01	01	H1036_121_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	121	0	1	01	01	H1036_121_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	121	0	1	01	01	H1036_121_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	121	0	1	01	01	H1036_121_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	121	0	1	01	01	H1036_121_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	121	0	1	01	01	H1036_121_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	122	0	1	01	01	H1036_122_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	122	0	1	01	01	H1036_122_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	122	0	1	01	01	H1036_122_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	122	0	1	01	01	H1036_122_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	122	0	1	01	01	H1036_122_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H1036	122	0	1	01	01	H1036_122_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H1036	122	0	1	01	01	H1036_122_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	122	0	1	01	01	H1036_122_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	125	0	1	01	01	H1036_125_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	125	0	1	01	01	H1036_125_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	125	0	1	01	01	H1036_125_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	125	0	1	01	01	H1036_125_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	125	0	1	01	01	H1036_125_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	125	0	1	01	01	H1036_125_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	125	0	1	01	01	H1036_125_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	125	0	1	01	01	H1036_125_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	126	0	1	01	01	H1036_126_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	126	0	1	01	01	H1036_126_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	126	0	1	01	01	H1036_126_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	126	0	1	01	01	H1036_126_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	126	0	1	01	01	H1036_126_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H1036	126	0	1	01	01	H1036_126_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	126	0	1	01	01	H1036_126_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	126	0	1	01	01	H1036_126_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	127	0	1	01	01	H1036_127_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	127	0	1	01	01	H1036_127_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	127	0	1	01	01	H1036_127_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	127	0	1	01	01	H1036_127_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	127	0	1	01	01	H1036_127_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1	10001000	2	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	127	0	1	01	01	H1036_127_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1036	127	0	1	01	01	H1036_127_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H1036	127	0	1	01	01	H1036_127_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	130	0	1	01	01	H1036_130_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	130	0	1	01	01	H1036_130_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	130	0	1	01	01	H1036_130_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	130	0	1	01	01	H1036_130_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	130	0	1	01	01	H1036_130_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	130	0	1	01	01	H1036_130_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	130	0	1	01	01	H1036_130_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	130	0	1	01	01	H1036_130_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	131	0	1	01	01	H1036_131_0	3	1	4	1	Other (Gen/Brand)	010010	3	2				Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	131	0	1	01	01	H1036_131_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	131	0	1	01	01	H1036_131_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	131	0	1	01	01	H1036_131_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1036	131	0	1	01	01	H1036_131_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1036	131	0	1	01	01	H1036_131_0	3	1	4	3	Other (Gen/Brand)	010010	3	2	1		1	Other (Gen/Brand)	111000000010000110110	30	90								30				30	90		30	90			34	Other (Gen/Brand)	2	2	Other (Gen/Brand)																						Other (Gen/Brand)	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1036	131	0	1	01	01	H1036_131_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1036	131	0	1	01	01	H1036_131_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1045	001	0	1	01	01	H1045_001_0	4	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	25.00	75.00								25.00		25.00	50.00								25.00
H1045	001	0	1	01	01	H1045_001_0	4	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	20.00								10.00
H1045	001	0	1	01	01	H1045_001_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1045	001	0	1	01	01	H1045_001_0	4	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1045	001	0	1	01	01	H1045_001_0	4	2	4	3	Tier 2	010001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1045	001	0	1	01	01	H1045_001_0	4	1	4	3	Tier 1	001010	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	001	0	1	01	01	H1045_001_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	20									20											20	Tier 4																					
H1045	001	0	1	01	01	H1045_001_0	4	1	4	1	Tier 1	001010	3	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	005	0	1	01	01	H1045_005_0	3	1	4	1	Tier 1	001010	1	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	005	0	1	01	01	H1045_005_0	3	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1045	005	0	1	01	01	H1045_005_0	3	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1045	005	0	1	01	01	H1045_005_0	3	1	4	3	Tier 1	001010	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	005	0	1	01	01	H1045_005_0	3	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	20									20											20	Tier 4																					
H1045	005	0	1	01	01	H1045_005_0	3	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	100.00								50.00
H1045	005	0	1	01	01	H1045_005_0	3	2	4	1	Tier 2	010001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	50.00								25.00
H1045	005	0	1	01	01	H1045_005_0	3	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1045	008	0	1	01	01	H1045_008_0	4	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H1045	008	0	1	01	01	H1045_008_0	4	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00
H1045	008	0	1	01	01	H1045_008_0	4	1	4	1	Tier 1	001010	3	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	008	0	1	01	01	H1045_008_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	20									20											20	Tier 4																					
H1045	008	0	1	01	01	H1045_008_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1045	008	0	1	01	01	H1045_008_0	4	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1045	008	0	1	01	01	H1045_008_0	4	2	4	3	Tier 2	010001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1045	008	0	1	01	01	H1045_008_0	4	1	4	3	Tier 1	001010	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	010	0	1	01	01	H1045_010_0	4	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	100.00								50.00
H1045	010	0	1	01	01	H1045_010_0	4	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	50.00								25.00
H1045	010	0	1	01	01	H1045_010_0	4	1	4	1	Tier 1	001010	3	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	010	0	1	01	01	H1045_010_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	20									20											20	Tier 4																					
H1045	011	0	1	01	01	H1045_011_0	5	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	100.00								50.00
H1045	011	0	1	01	01	H1045_011_0	5	2	4	1	Tier 2	010001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	60.00								30.00
H1045	011	0	1	01	01	H1045_011_0	5	1	4	1	Tier 1	001010	1	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	10.00								5.00
H1045	011	0	1	01	01	H1045_011_0	5	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	20									20											20	Tier 4																					
H1045	014	0	1	02	01	H1045_014_0	9	1	4	1	Tier 1	001010	3	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	014	0	1	02	01	H1045_014_0	9	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	20.00								10.00
H1045	014	0	1	02	01	H1045_014_0	9	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	25.00	75.00								25.00		25.00	50.00								25.00
H1045	014	0	1	02	01	H1045_014_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	33									33											33	Tier 4																					
H1045	015	0	1	02	01	H1045_015_0	7	3	4	1	Tier 3	110000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	34	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	100.00								50.00
H1045	015	0	1	02	01	H1045_015_0	7	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010110000000	30	90								30		30								90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	50.00								25.00
H1045	015	0	1	02	01	H1045_015_0	7	1	4	1	Tier 1	001010	3	2				Tier 1	111000000010110000000	30	90								30		30								90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H1045	015	0	1	02	01	H1045_015_0	7	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											34	Tier 4	2	1	Tier 4	33									33											33	Tier 4																					
H1076	003	0	1	01	01	H1076_003_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1076	003	0	1	01	01	H1076_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00		20.00	40.00								20.00
H1076	003	0	1	01	01	H1076_003_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H1076	003	0	1	01	01	H1076_003_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H1076	003	0	1	01	01	H1076_003_0	6	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1076	003	0	1	01	01	H1076_003_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1076	003	0	1	01	01	H1076_003_0	6	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1076	003	0	1	01	01	H1076_003_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1076	011	0	1	01	01	H1076_011_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1076	011	0	1	01	01	H1076_011_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H1076	011	0	1	01	01	H1076_011_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H1076	011	0	1	01	01	H1076_011_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00											76.00
H1076	016	0	1	01	01	H1076_016_0	8	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1076	016	0	1	01	01	H1076_016_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00		30.00	60.00								30.00
H1076	016	0	1	01	01	H1076_016_0	8	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H1076	016	0	1	01	01	H1076_016_0	8	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H1076	016	0	1	01	01	H1076_016_0	8	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H1076	016	0	1	01	01	H1076_016_0	8	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1076	016	0	1	01	01	H1076_016_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1076	016	0	1	01	01	H1076_016_0	8	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1080	004	0	1	01	01	H1080_004_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H1080	004	0	1	01	01	H1080_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H1080	004	0	1	01	01	H1080_004_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1080	004	0	1	01	01	H1080_004_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1080	011	0	1	02	01	H1080_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H1080	011	0	1	02	01	H1080_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H1080	011	0	1	02	01	H1080_011_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1080	011	0	1	02	01	H1080_011_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1080	042	0	1	01	01	H1080_042_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1080	042	0	1	01	01	H1080_042_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1080	042	0	1	01	01	H1080_042_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1080	042	0	1	01	01	H1080_042_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1099	001	0	1	02	01	H1099_001_0	4	3	4	3	Tier 3 Brand	000010	1	2	2			Tier 3 Brand																							Tier 3 Brand			Tier 3 Brand																						Tier 3 Brand																					
H1099	001	0	1	02	01	H1099_001_0	4	2	4	3	Tier 2 Generic	010000	1	2	1		1	Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	001	0	1	02	01	H1099_001_0	4	1	4	3	Tier 1 Preferred Generic	001000	1	2	1		1	Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	001	0	1	02	01	H1099_001_0	4	4	4	1	Tier 4 Specialty	000010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1099	001	0	1	02	01	H1099_001_0	4	3	4	1	Tier 3 Brand	000010	1	2				Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	40.00	120.00								40.00			80.00								40.00
H1099	001	0	1	02	01	H1099_001_0	4	2	4	1	Tier 2 Generic	010000	1	2				Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	001	0	1	02	01	H1099_001_0	4	1	4	1	Tier 1 Preferred Generic	001000	1	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	001	0	1	02	01	H1099_001_0	4	4	4	3	Tier 4 Specialty	000010	1	1	2			Tier 4 Specialty																							Tier 4 Specialty			Tier 4 Specialty																						Tier 4 Specialty																					
H1099	006	0	1	01	01	H1099_006_0	4	3	4	3	Tier 3 Brand	000010	1	2	2			Tier 3 Brand																							Tier 3 Brand			Tier 3 Brand																						Tier 3 Brand																					
H1099	006	0	1	01	01	H1099_006_0	4	2	4	3	Tier 2 Generic	010000	1	2	2			Tier 2 Generic																							Tier 2 Generic			Tier 2 Generic																						Tier 2 Generic																					
H1099	006	0	1	01	01	H1099_006_0	4	1	4	3	Tier 1 Preferred Generic	001000	1	2	1		1	Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	006	0	1	01	01	H1099_006_0	4	4	4	1	Tier 4 Specialty	000010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1099	006	0	1	01	01	H1099_006_0	4	3	4	1	Tier 3 Brand	000010	1	2				Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	45.00	135.00								45.00			90.00								45.00
H1099	006	0	1	01	01	H1099_006_0	4	2	4	1	Tier 2 Generic	010000	1	2				Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	006	0	1	01	01	H1099_006_0	4	1	4	1	Tier 1 Preferred Generic	001000	1	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	006	0	1	01	01	H1099_006_0	4	4	4	3	Tier 4 Specialty	000010	1	1	2			Tier 4 Specialty																							Tier 4 Specialty			Tier 4 Specialty																						Tier 4 Specialty																					
H1099	010	0	1	01	01	H1099_010_0	4	1	4	1	Tier 1 Preferred Generic	001000	1	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	010	0	1	01	01	H1099_010_0	4	2	4	1	Tier 2 Generic	010000	1	2				Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	010	0	1	01	01	H1099_010_0	4	4	4	3	Tier 4 Specialty	000010	1	1	1		1	Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1099	010	0	1	01	01	H1099_010_0	4	3	4	3	Tier 3 Brand	000010	1	2	1		1	Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	40.00	120.00								40.00			80.00								40.00
H1099	010	0	1	01	01	H1099_010_0	4	2	4	3	Tier 2 Generic	010000	1	2	1		1	Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	010	0	1	01	01	H1099_010_0	4	1	4	3	Tier 1 Preferred Generic	001000	1	2	1		1	Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	010	0	1	01	01	H1099_010_0	4	4	4	1	Tier 4 Specialty	000010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1099	010	0	1	01	01	H1099_010_0	4	3	4	1	Tier 3 Brand	000010	1	2				Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	40.00	120.00								40.00			80.00								40.00
H1099	011	0	1	02	01	H1099_011_0	4	1	4	1	Tier 1 Preferred Generic	001000	1	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	011	0	1	02	01	H1099_011_0	4	3	4	3	Tier 3 Brand	000010	1	2	1		1	Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	40.00	120.00								40.00			80.00								40.00
H1099	011	0	1	02	01	H1099_011_0	4	2	4	3	Tier 2 Generic	010000	1	2	1		1	Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	011	0	1	02	01	H1099_011_0	4	1	4	3	Tier 1 Preferred Generic	001000	1	2	1		1	Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00
H1099	011	0	1	02	01	H1099_011_0	4	4	4	1	Tier 4 Specialty	000010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1099	011	0	1	02	01	H1099_011_0	4	3	4	1	Tier 3 Brand	000010	1	2				Tier 3 Brand	111000000010010000000	30	90								30										90	31	Tier 3 Brand	2	2	Tier 3 Brand																						Tier 3 Brand	40.00	120.00								40.00			80.00								40.00
H1099	011	0	1	02	01	H1099_011_0	4	2	4	1	Tier 2 Generic	010000	1	2				Tier 2 Generic	111000000010010000000	30	90								30										90	31	Tier 2 Generic	2	2	Tier 2 Generic																						Tier 2 Generic	5.00	15.00								5.00			10.00								5.00
H1099	011	0	1	02	01	H1099_011_0	4	4	4	3	Tier 4 Specialty	000010	1	1	1		1	Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
H1108	001	0	1	04	01	H1108_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H1108	001	0	1	04	01	H1108_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1108	001	0	1	04	01	H1108_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H1108	001	0	1	04	01	H1108_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1108	006	0	1	04	01	H1108_006_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1108	006	0	1	04	01	H1108_006_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1108	006	0	1	04	01	H1108_006_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1108	006	0	1	04	01	H1108_006_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H1108	006	0	1	04	01	H1108_006_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1108	006	0	1	04	01	H1108_006_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1108	006	0	1	04	01	H1108_006_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1108	006	0	1	04	01	H1108_006_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1108	007	0	1	04	01	H1108_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00						4.00			6.00		2.00
H1108	007	0	1	04	01	H1108_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1108	007	0	1	04	01	H1108_007_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1108	007	0	1	04	01	H1108_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1109	001	0	1	01	01	H1109_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H1109	001	0	1	01	01	H1109_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H1109	001	0	1	01	01	H1109_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H1109	001	0	1	01	01	H1109_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1109	001	0	1	01	01	H1109_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H1109	002	0	1	01	01	H1109_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1109	002	0	1	01	01	H1109_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H1109	002	0	1	01	01	H1109_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H1109	002	0	1	01	01	H1109_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H1109	002	0	1	01	01	H1109_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H1109	003	0	1	01	01	H1109_003_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H1109	003	0	1	01	01	H1109_003_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H1109	003	0	1	01	01	H1109_003_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H1109	003	0	1	01	01	H1109_003_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H1109	003	0	1	01	01	H1109_003_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H1109	003	0	1	01	01	H1109_003_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H1109	003	0	1	01	01	H1109_003_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H1109	003	0	1	01	01	H1109_003_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H1109	003	0	1	01	01	H1109_003_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H1109	003	0	1	01	01	H1109_003_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H1110	001	0	1	04	01	H1110_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H1110	001	0	1	04	01	H1110_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H1110	001	0	1	04	01	H1110_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
H1110	001	0	1	04	01	H1110_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H1110	001	0	1	04	01	H1110_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1110	003	0	1	04	01	H1110_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H1110	003	0	1	04	01	H1110_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H1110	003	0	1	04	01	H1110_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H1110	003	0	1	04	01	H1110_003_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H1110	003	0	1	04	01	H1110_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H1110	003	0	1	04	01	H1110_003_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H1110	003	0	1	04	01	H1110_003_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H1110	003	0	1	04	01	H1110_003_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H1110	003	0	1	04	01	H1110_003_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H1110	003	0	1	04	01	H1110_003_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H1111	002	0	1	02	01	H1111_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1111	002	0	1	02	01	H1111_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1111	002	0	1	02	01	H1111_002_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1111	002	0	1	02	01	H1111_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00						4.00			6.00		2.00
H1111	005	0	1	02	01	H1111_005_0	3	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H1111	005	0	1	02	01	H1111_005_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1111	005	0	1	02	01	H1111_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1111	005	0	1	02	01	H1111_005_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1111	005	0	1	02	01	H1111_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1111	005	0	1	02	01	H1111_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1111	005	0	1	02	01	H1111_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1111	005	0	1	02	01	H1111_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1112	001	0	1	01	01	H1112_001_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1112	001	0	1	01	01	H1112_001_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1112	001	0	1	01	01	H1112_001_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1112	001	0	1	01	01	H1112_001_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	001	0	1	01	01	H1112_001_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1112	001	0	1	01	01	H1112_001_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1112	001	0	1	01	01	H1112_001_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1112	001	0	1	01	01	H1112_001_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	005	0	1	01	01	H1112_005_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1112	005	0	1	01	01	H1112_005_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1112	005	0	1	01	01	H1112_005_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	005	0	1	01	01	H1112_005_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1112	006	0	1	01	01	H1112_006_0	9	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1112	006	0	1	01	01	H1112_006_0	9	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	006	0	1	01	01	H1112_006_0	9	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1112	006	0	1	01	01	H1112_006_0	9	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1112	027	0	1	01	01	H1112_027_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H1112	027	0	1	01	01	H1112_027_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00
H1112	027	0	1	01	01	H1112_027_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1112	027	0	1	01	01	H1112_027_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1112	027	0	1	01	01	H1112_027_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1112	027	0	1	01	01	H1112_027_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	027	0	1	01	01	H1112_027_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1112	027	0	1	01	01	H1112_027_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	030	0	1	01	01	H1112_030_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1112	030	0	1	01	01	H1112_030_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1112	030	0	1	01	01	H1112_030_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1112	030	0	1	01	01	H1112_030_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
H1170	002	0	1	01	01	H1170_002_0	11	1	4	1	Generic	010000	1	2				Generic	100011010010110000000				30	90		30			30		30								90	31	Generic	2	2	Generic																						Generic				8.00	24.00		24.00			24.00		8.00	16.00								24.00
H1170	002	0	1	01	01	H1170_002_0	11	2	4	1	Brand	000010	1	2				Brand	100011010010110000000				30	90		30			30		30								90	31	Brand	2	2	Brand																						Brand				40.00	120.00		60.00			60.00		40.00	80.00								60.00
H1170	002	0	1	01	01	H1170_002_0	11	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1170	002	0	1	01	01	H1170_002_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	100011010010110000000				30	90		30			30		30								90	31	Generic	2	2	Generic																						Generic				8.00	24.00		24.00			24.00		8.00	16.00								24.00
H1170	002	0	1	01	01	H1170_002_0	11	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H1170	002	0	1	01	01	H1170_002_0	11	3	4	1	Specialty	000010	1	1				Specialty	100011010010110000000				30	90		30			30		30								90	31	Specialty	2	1	Specialty				25	25		25			25		25	25								25	Specialty																					
H1170	008	0	1	01	01	H1170_008_0	12	3	3	1	Specialty	000010		1				Specialty	100011010010110000000				30	90		30			30		30								90	31	Specialty	2	1	Specialty				25	25		25			25		25	25								25	Specialty																					
H1170	008	0	1	01	01	H1170_008_0	12	1	3	1	Generic	010000		2				Generic	100011010010110000000				30	90		30			30		30								90	31	Generic	2	2	Generic																						Generic				10.00	30.00		24.00			24.00		10.00	20.00								24.00
H1170	008	0	1	01	01	H1170_008_0	12	2	3	1	Brand	000010		2				Brand	100011010010110000000				30	90		30			30		30								90	31	Brand	2	2	Brand																						Brand				38.00	114.00		60.00			60.00		38.00	76.00								60.00
H1170	009	0	1	01	01	H1170_009_0	9	1	4	1	Generic	010000	1	2				Generic	100011010010110000000				30	90		30			30		30								90	31	Generic	2	2	Generic																						Generic				10.00	30.00		24.00			24.00		10.00	20.00								24.00
H1170	009	0	1	01	01	H1170_009_0	9	2	4	1	Brand	000010	1	2				Brand	100011010010110000000				30	90		30			30		30								90	31	Brand	2	2	Brand																						Brand				40.00	120.00		60.00			60.00		40.00	80.00								60.00
H1170	009	0	1	01	01	H1170_009_0	9	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1170	009	0	1	01	01	H1170_009_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	100011010010110000000				30	90		30			30		30								90	31	Generic	2	2	Generic																						Generic				10.00	30.00		24.00			24.00		10.00	20.00								24.00
H1170	009	0	1	01	01	H1170_009_0	9	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H1170	009	0	1	01	01	H1170_009_0	9	3	4	1	Specialty	000010	1	1				Specialty	100011010010110000000				30	90		30			30		30								90	31	Specialty	2	1	Specialty				25	25		25			25		25	25								25	Specialty																					
H1216	001	0	1	02	01	H1216_001_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1216	001	0	1	02	01	H1216_001_0	9	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1216	001	0	1	02	01	H1216_001_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1216	001	0	1	02	01	H1216_001_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1216	001	0	1	02	01	H1216_001_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1216	001	0	1	02	01	H1216_001_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H1216	001	0	1	02	01	H1216_001_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1216	001	0	1	02	01	H1216_001_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1216	003	0	1	01	01	H1216_003_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1216	003	0	1	01	01	H1216_003_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1216	003	0	1	01	01	H1216_003_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1216	003	0	1	01	01	H1216_003_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1216	004	0	1	02	01	H1216_004_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1216	004	0	1	02	01	H1216_004_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00
H1216	004	0	1	02	01	H1216_004_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1216	004	0	1	02	01	H1216_004_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1230	001	0	1	01	01	H1230_001_0	11	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1230	001	0	1	01	01	H1230_001_0	11	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H1230	001	0	1	01	01	H1230_001_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H1230	001	0	1	01	01	H1230_001_0	11	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1230	001	0	1	01	01	H1230_001_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H1230	001	0	1	01	01	H1230_001_0	11	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00
H1230	003	0	1	01	01	H1230_003_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H1230	003	0	1	01	01	H1230_003_0	11	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00
H1230	003	0	1	01	01	H1230_003_0	11	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1230	003	0	1	01	01	H1230_003_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H1230	003	0	1	01	01	H1230_003_0	11	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H1230	003	0	1	01	01	H1230_003_0	11	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1251	003	0	1	18	06	H1251_003_0	5	3	2	1	Other Brand	100000		2				Other Brand	111000000010010000000	30	90								30										90	34	Other Brand	1	2	Other Brand																						Other Brand	60.00	180.00								60.00			120.00								60.00
H1251	003	0	1	18	06	H1251_003_0	5	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H1251	003	0	1	18	06	H1251_003_0	5	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H1251	003	0	1	18	06	H1251_003_0	5	4	2	1	Injectables	100000		2				Injectables	111000000010000000000	30	90								30											34	Injectables	2	1	Injectables	25	25								25											25	Injectables																					
H1251	003	0	1	18	06	H1251_003_0	5	5	2	1	Specialty Drugs	100000		1				Specialty Drugs	111000000010000000000	30	90								30											34	Specialty Drugs	2	1	Specialty Drugs	25	25								25											25	Specialty Drugs																					
H1251	004	0	1	18	06	H1251_004_0	5	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H1251	004	0	1	18	06	H1251_004_0	5	3	2	1	Other Brand	100000		2				Other Brand	111000000010010000000	30	90								30										90	34	Other Brand	1	2	Other Brand																						Other Brand	60.00	180.00								60.00			120.00								60.00
H1251	004	0	1	18	06	H1251_004_0	5	5	2	1	Specialty Drugs	100000		1				Specialty Drugs	111000000010000000000	30	90								30											34	Specialty Drugs	2	1	Specialty Drugs	25	25								25											25	Specialty Drugs																					
H1251	004	0	1	18	06	H1251_004_0	5	4	2	1	Injectables	100000		2				Injectables	111000000010000000000	30	90								30											34	Injectables	2	1	Injectables	25	25								25											25	Injectables																					
H1251	004	0	1	18	06	H1251_004_0	5	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H1251	011	0	1	18	06	H1251_011_0	5	3	2	1	Other Brand	100000		2				Other Brand	111000000010010000000	30	90								30										90	34	Other Brand	1	2	Other Brand																						Other Brand	60.00	180.00								60.00			120.00								60.00
H1251	011	0	1	18	06	H1251_011_0	5	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H1251	011	0	1	18	06	H1251_011_0	5	5	2	1	Specialty Drugs	100000		1				Specialty Drugs	111000000010000000000	30	90								30											34	Specialty Drugs	2	1	Specialty Drugs	25	25								25											25	Specialty Drugs																					
H1251	011	0	1	18	06	H1251_011_0	5	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H1251	011	0	1	18	06	H1251_011_0	5	4	2	1	Injectables	100000		2				Injectables	111000000010000000000	30	90								30											34	Injectables	2	1	Injectables	25	25								25											25	Injectables																					
H1264	004	0	1	02	01	H1264_004_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1264	004	0	1	02	01	H1264_004_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1264	004	0	1	02	01	H1264_004_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	004	0	1	02	01	H1264_004_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1264	004	0	1	02	01	H1264_004_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1264	004	0	1	02	01	H1264_004_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1264	004	0	1	02	01	H1264_004_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	004	0	1	02	01	H1264_004_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1264	005	0	1	02	01	H1264_005_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	005	0	1	02	01	H1264_005_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1264	005	0	1	02	01	H1264_005_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1264	005	0	1	02	01	H1264_005_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1264	005	0	1	02	01	H1264_005_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	005	0	1	02	01	H1264_005_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1264	005	0	1	02	01	H1264_005_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1264	005	0	1	02	01	H1264_005_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1264	006	0	1	01	01	H1264_006_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
H1264	006	0	1	01	01	H1264_006_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1264	006	0	1	01	01	H1264_006_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	006	0	1	01	01	H1264_006_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1264	007	0	1	01	01	H1264_007_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
H1264	007	0	1	01	01	H1264_007_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1264	007	0	1	01	01	H1264_007_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	007	0	1	01	01	H1264_007_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1264	008	0	1	02	01	H1264_008_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	008	0	1	02	01	H1264_008_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1264	008	0	1	02	01	H1264_008_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1264	008	0	1	02	01	H1264_008_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1264	008	0	1	02	01	H1264_008_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1264	008	0	1	02	01	H1264_008_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1264	008	0	1	02	01	H1264_008_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	008	0	1	02	01	H1264_008_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1264	009	0	1	02	01	H1264_009_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1264	009	0	1	02	01	H1264_009_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1264	009	0	1	02	01	H1264_009_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	009	0	1	02	01	H1264_009_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1264	010	0	1	02	01	H1264_010_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1264	010	0	1	02	01	H1264_010_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1264	010	0	1	02	01	H1264_010_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1264	010	0	1	02	01	H1264_010_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	011	0	1	02	01	H1264_011_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	011	0	1	02	01	H1264_011_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1264	011	0	1	02	01	H1264_011_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1264	011	0	1	02	01	H1264_011_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1264	013	0	1	02	01	H1264_013_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	013	0	1	02	01	H1264_013_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1264	013	0	1	02	01	H1264_013_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1264	013	0	1	02	01	H1264_013_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1264	013	0	1	02	01	H1264_013_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	013	0	1	02	01	H1264_013_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1264	013	0	1	02	01	H1264_013_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1264	013	0	1	02	01	H1264_013_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1264	014	0	1	02	01	H1264_014_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	014	0	1	02	01	H1264_014_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1264	014	0	1	02	01	H1264_014_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1264	014	0	1	02	01	H1264_014_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1264	014	0	1	02	01	H1264_014_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	014	0	1	02	01	H1264_014_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1264	014	0	1	02	01	H1264_014_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1264	014	0	1	02	01	H1264_014_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1264	016	0	1	01	01	H1264_016_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1264	016	0	1	01	01	H1264_016_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1264	016	0	1	01	01	H1264_016_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	87.00	261.00								87.00			261.00								87.00
H1264	016	0	1	01	01	H1264_016_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1286	001	0	1	02	01	H1286_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1286	001	0	1	02	01	H1286_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1286	001	0	1	02	01	H1286_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H1286	001	0	1	02	01	H1286_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H1286	002	0	1	02	01	H1286_002_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1286	002	0	1	02	01	H1286_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1286	002	0	1	02	01	H1286_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1286	002	0	1	02	01	H1286_002_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1286	004	0	1	02	01	H1286_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H1286	004	0	1	02	01	H1286_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H1286	004	0	1	02	01	H1286_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H1286	004	0	1	02	01	H1286_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1286	007	0	1	02	01	H1286_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1286	007	0	1	02	01	H1286_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1286	007	0	1	02	01	H1286_007_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1286	007	0	1	02	01	H1286_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1286	008	0	1	02	01	H1286_008_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1286	008	0	1	02	01	H1286_008_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1286	008	0	1	02	01	H1286_008_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1286	008	0	1	02	01	H1286_008_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1302	001	0	1	04	01	H1302_001_0	13	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H1302	001	0	1	04	01	H1302_001_0	13	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H1302	001	0	1	04	01	H1302_001_0	13	4	4	1	Injectable Drugs	110001	1	2				Injectable Drugs	111000000010110000000	30	90								30		30								90	31	Injectable Drugs	2	1	Injectable Drugs	25	25								25		25	25								25	Injectable Drugs																					
H1302	001	0	1	04	01	H1302_001_0	13	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00		6.00	18.00								6.00
H1302	001	0	1	04	01	H1302_001_0	13	5	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H1303	001	0	1	04	01	H1303_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1303	001	0	1	04	01	H1303_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H1303	001	0	1	04	01	H1303_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H1303	001	0	1	04	01	H1303_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H1303	006	0	1	04	01	H1303_006_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1303	006	0	1	04	01	H1303_006_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1303	006	0	1	04	01	H1303_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1303	006	0	1	04	01	H1303_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1304	002	0	1	04	01	H1304_002_0	7	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H1304	002	0	1	04	01	H1304_002_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H1304	002	0	1	04	01	H1304_002_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H1304	002	0	1	04	01	H1304_002_0	7	5	2	1	Specialty Medications	110001		1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H1304	002	0	1	04	01	H1304_002_0	7	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H1304	004	0	1	04	01	H1304_004_0	7	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H1304	004	0	1	04	01	H1304_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H1304	004	0	1	04	01	H1304_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H1304	004	0	1	04	01	H1304_004_0	7	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H1304	004	0	1	04	01	H1304_004_0	7	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H1304	004	0	1	04	01	H1304_004_0	7	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H1304	004	0	1	04	01	H1304_004_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1304	004	0	1	04	01	H1304_004_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1304	004	0	1	04	01	H1304_004_0	7	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
H1304	004	0	1	04	01	H1304_004_0	7	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
H1304	006	0	1	04	01	H1304_006_0	6	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H1304	006	0	1	04	01	H1304_006_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H1304	006	0	1	04	01	H1304_006_0	6	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H1304	006	0	1	04	01	H1304_006_0	6	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H1304	006	0	1	04	01	H1304_006_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H1317	002	0	1	04	01	H1317_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H1317	002	0	1	04	01	H1317_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H1317	002	0	1	04	01	H1317_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H1317	002	0	1	04	01	H1317_002_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1317	002	0	1	04	01	H1317_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H1317	002	0	1	04	01	H1317_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1317	002	0	1	04	01	H1317_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1317	002	0	1	04	01	H1317_002_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H1340	014	0	1	09	04	H1340_014_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1340	014	0	1	09	04	H1340_014_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1340	014	0	1	09	04	H1340_014_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1340	014	0	1	09	04	H1340_014_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1340	033	0	1	09	04	H1340_033_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H1340	033	0	1	09	04	H1340_033_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1340	033	0	1	09	04	H1340_033_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1340	033	0	1	09	04	H1340_033_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1340	034	0	1	09	04	H1340_034_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H1340	034	0	1	09	04	H1340_034_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1340	034	0	1	09	04	H1340_034_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1340	034	0	1	09	04	H1340_034_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1340	035	0	1	09	04	H1340_035_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H1340	035	0	1	09	04	H1340_035_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1340	035	0	1	09	04	H1340_035_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1340	035	0	1	09	04	H1340_035_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1340	036	0	1	09	04	H1340_036_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H1340	036	0	1	09	04	H1340_036_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H1340	036	0	1	09	04	H1340_036_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H1340	036	0	1	09	04	H1340_036_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1350	001	0	1	01	01	H1350_001_0	15	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00								6.00		6.00	18.00								6.00
H1350	001	0	1	01	01	H1350_001_0	15	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00
H1350	001	0	1	01	01	H1350_001_0	15	3	4	1	Tier 3 - Non Preferred Brand	100000	1	2				Tier 3 - Non Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Non Preferred Brand	2	2	Tier 3 - Non Preferred Brand																						Tier 3 - Non Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H1350	001	0	1	01	01	H1350_001_0	15	4	4	1	Tier 4 - Injectable Drugs	010011	1	2				Tier 4 - Injectable Drugs	111000000010110000000	30	90								30		30								90	31	Tier 4 - Injectable Drugs	2	1	Tier 4 - Injectable Drugs	25	25								25		25	25								25	Tier 4 - Injectable Drugs																					
H1350	001	0	1	01	01	H1350_001_0	15	5	4	3	Tier 5 - Specialty Drugs	010011	1	1	2			Tier 5 - Specialty Drugs																							Tier 5 - Specialty Drugs			Tier 5 - Specialty Drugs																						Tier 5 - Specialty Drugs																					
H1350	001	0	1	01	01	H1350_001_0	15	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00								6.00		6.00	18.00								6.00
H1350	001	0	1	01	01	H1350_001_0	15	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H1350	001	0	1	01	01	H1350_001_0	15	3	4	3	Tier 3 - Non Preferred Brand	100000	1	2	2			Tier 3 - Non Preferred Brand																							Tier 3 - Non Preferred Brand			Tier 3 - Non Preferred Brand																						Tier 3 - Non Preferred Brand																					
H1350	001	0	1	01	01	H1350_001_0	15	4	4	3	Tier 4 - Injectable Drugs	010011	1	2	2			Tier 4 - Injectable Drugs																							Tier 4 - Injectable Drugs			Tier 4 - Injectable Drugs																						Tier 4 - Injectable Drugs																					
H1350	001	0	1	01	01	H1350_001_0	15	5	4	1	Tier 5 - Specialty Drugs	010011	1	1				Tier 5 - Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Tier 5 - Specialty Drugs	2	1	Tier 5 - Specialty Drugs	25	25								25		25	25								25	Tier 5 - Specialty Drugs																					
H1355	001	0	1	04	01	H1355_001_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H1355	001	0	1	04	01	H1355_001_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H1355	001	0	1	04	01	H1355_001_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H1355	001	0	1	04	01	H1355_001_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H1356	002	0	1	04	01	H1356_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H1356	002	0	1	04	01	H1356_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1356	002	0	1	04	01	H1356_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1356	002	0	1	04	01	H1356_002_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1356	002	0	1	04	01	H1356_002_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H1356	002	0	1	04	01	H1356_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H1356	002	0	1	04	01	H1356_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H1356	002	0	1	04	01	H1356_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H1364	006	0	1	01	01	H1364_006_0	10	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H1364	006	0	1	01	01	H1364_006_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H1364	006	0	1	01	01	H1364_006_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H1364	006	0	1	01	01	H1364_006_0	10	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H1364	007	0	1	01	01	H1364_007_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H1364	007	0	1	01	01	H1364_007_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1364	007	0	1	01	01	H1364_007_0	7	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1364	007	0	1	01	01	H1364_007_0	7	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H1364	007	0	1	01	01	H1364_007_0	7	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H1364	007	0	1	01	01	H1364_007_0	7	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H1364	007	0	1	01	01	H1364_007_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H1364	007	0	1	01	01	H1364_007_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H1406	013	0	1	01	01	H1406_013_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1406	013	0	1	01	01	H1406_013_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1406	013	0	1	01	01	H1406_013_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1406	013	0	1	01	01	H1406_013_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1406	013	0	1	01	01	H1406_013_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1406	013	0	1	01	01	H1406_013_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1406	013	0	1	01	01	H1406_013_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1406	013	0	1	01	01	H1406_013_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1406	022	0	1	01	01	H1406_022_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1406	022	0	1	01	01	H1406_022_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1406	022	0	1	01	01	H1406_022_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1406	022	0	1	01	01	H1406_022_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1406	022	0	1	01	01	H1406_022_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1406	022	0	1	01	01	H1406_022_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1406	022	0	1	01	01	H1406_022_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1406	022	0	1	01	01	H1406_022_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1406	024	0	1	01	01	H1406_024_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1406	024	0	1	01	01	H1406_024_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1406	024	0	1	01	01	H1406_024_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00					90.00	225.00		90.00	270.00		90.00
H1406	024	0	1	01	01	H1406_024_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00					90.00	225.00		90.00	270.00		90.00
H1406	024	0	1	01	01	H1406_024_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1406	024	0	1	01	01	H1406_024_0	3	1	4	3	Preferred Generic	001000	3	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1406	024	0	1	01	01	H1406_024_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1406	024	0	1	01	01	H1406_024_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1415	015	0	1	01	01	H1415_015_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H1415	015	0	1	01	01	H1415_015_0	5	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H1415	015	0	1	01	01	H1415_015_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H1415	015	0	1	01	01	H1415_015_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H1415	015	0	1	01	01	H1415_015_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H1415	015	0	1	01	01	H1415_015_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H1415	015	0	1	01	01	H1415_015_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H1415	015	0	1	01	01	H1415_015_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1415	015	0	1	01	01	H1415_015_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1415	015	0	1	01	01	H1415_015_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1415	017	0	1	02	01	H1415_017_0	7	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H1415	017	0	1	02	01	H1415_017_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1415	017	0	1	02	01	H1415_017_0	7	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H1415	017	0	1	02	01	H1415_017_0	7	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H1415	017	0	1	02	01	H1415_017_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1415	017	0	1	02	01	H1415_017_0	7	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H1415	017	0	1	02	01	H1415_017_0	7	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1415	017	0	1	02	01	H1415_017_0	7	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1415	017	0	1	02	01	H1415_017_0	7	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1415	017	0	1	02	01	H1415_017_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H1415	021	0	1	02	01	H1415_021_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1415	021	0	1	02	01	H1415_021_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1415	021	0	1	02	01	H1415_021_0	6	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1415	021	0	1	02	01	H1415_021_0	6	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H1415	021	0	1	02	01	H1415_021_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H1415	021	0	1	02	01	H1415_021_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H1415	021	0	1	02	01	H1415_021_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H1415	021	0	1	02	01	H1415_021_0	6	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H1415	021	0	1	02	01	H1415_021_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H1415	021	0	1	02	01	H1415_021_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1416	002	0	1	02	01	H1416_002_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1416	002	0	1	02	01	H1416_002_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1416	002	0	1	02	01	H1416_002_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1416	002	0	1	02	01	H1416_002_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	002	0	1	02	01	H1416_002_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	002	0	1	02	01	H1416_002_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	002	0	1	02	01	H1416_002_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	002	0	1	02	01	H1416_002_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H1416	003	0	1	02	01	H1416_003_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1416	003	0	1	02	01	H1416_003_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	003	0	1	02	01	H1416_003_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	003	0	1	02	01	H1416_003_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1416	007	0	1	01	01	H1416_007_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	007	0	1	01	01	H1416_007_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	007	0	1	01	01	H1416_007_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1416	007	0	1	01	01	H1416_007_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1416	009	0	1	02	01	H1416_009_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	009	0	1	02	01	H1416_009_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	009	0	1	02	01	H1416_009_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1416	009	0	1	02	01	H1416_009_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1416	009	0	1	02	01	H1416_009_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1416	009	0	1	02	01	H1416_009_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	009	0	1	02	01	H1416_009_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	009	0	1	02	01	H1416_009_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	013	0	1	02	01	H1416_013_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1416	013	0	1	02	01	H1416_013_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	013	0	1	02	01	H1416_013_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	013	0	1	02	01	H1416_013_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1416	014	0	1	02	01	H1416_014_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1416	014	0	1	02	01	H1416_014_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1416	014	0	1	02	01	H1416_014_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	014	0	1	02	01	H1416_014_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	014	0	1	02	01	H1416_014_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	014	0	1	02	01	H1416_014_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	014	0	1	02	01	H1416_014_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	014	0	1	02	01	H1416_014_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1416	017	0	1	02	01	H1416_017_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	017	0	1	02	01	H1416_017_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1416	017	0	1	02	01	H1416_017_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
H1416	017	0	1	02	01	H1416_017_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1416	018	0	1	02	01	H1416_018_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	018	0	1	02	01	H1416_018_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1416	018	0	1	02	01	H1416_018_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1416	018	0	1	02	01	H1416_018_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	018	0	1	02	01	H1416_018_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	018	0	1	02	01	H1416_018_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1416	018	0	1	02	01	H1416_018_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	018	0	1	02	01	H1416_018_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H1416	019	0	1	02	01	H1416_019_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	019	0	1	02	01	H1416_019_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	019	0	1	02	01	H1416_019_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	019	0	1	02	01	H1416_019_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	020	0	1	02	01	H1416_020_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	020	0	1	02	01	H1416_020_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1416	020	0	1	02	01	H1416_020_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	020	0	1	02	01	H1416_020_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1416	021	0	1	02	01	H1416_021_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1416	021	0	1	02	01	H1416_021_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00
H1416	021	0	1	02	01	H1416_021_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1416	021	0	1	02	01	H1416_021_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1417	002	0	1	04	01	H1417_002_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	002	0	1	04	01	H1417_002_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	002	0	1	04	01	H1417_002_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	002	0	1	04	01	H1417_002_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	004	0	1	04	01	H1417_004_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	004	0	1	04	01	H1417_004_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	004	0	1	04	01	H1417_004_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	004	0	1	04	01	H1417_004_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	005	0	1	04	01	H1417_005_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	005	0	1	04	01	H1417_005_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	005	0	1	04	01	H1417_005_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	005	0	1	04	01	H1417_005_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	005	0	1	04	01	H1417_005_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	005	0	1	04	01	H1417_005_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1417	005	0	1	04	01	H1417_005_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1417	005	0	1	04	01	H1417_005_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1417	006	0	1	04	01	H1417_006_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	006	0	1	04	01	H1417_006_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1417	006	0	1	04	01	H1417_006_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	006	0	1	04	01	H1417_006_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	006	0	1	04	01	H1417_006_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	006	0	1	04	01	H1417_006_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1417	006	0	1	04	01	H1417_006_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1417	006	0	1	04	01	H1417_006_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	008	0	1	04	01	H1417_008_0	10	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	008	0	1	04	01	H1417_008_0	10	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	008	0	1	04	01	H1417_008_0	10	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	008	0	1	04	01	H1417_008_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	009	0	1	04	01	H1417_009_0	10	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1417	009	0	1	04	01	H1417_009_0	10	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1417	009	0	1	04	01	H1417_009_0	10	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	009	0	1	04	01	H1417_009_0	10	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1417	009	0	1	04	01	H1417_009_0	10	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1417	009	0	1	04	01	H1417_009_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1417	009	0	1	04	01	H1417_009_0	10	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1417	009	0	1	04	01	H1417_009_0	10	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1418	002	0	1	04	01	H1418_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H1418	002	0	1	04	01	H1418_002_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1418	002	0	1	04	01	H1418_002_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H1418	002	0	1	04	01	H1418_002_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1418	002	0	1	04	01	H1418_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H1418	002	0	1	04	01	H1418_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1418	002	0	1	04	01	H1418_002_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H1418	002	0	1	04	01	H1418_002_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1418	007	0	1	04	01	H1418_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1418	007	0	1	04	01	H1418_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1418	007	0	1	04	01	H1418_007_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1418	007	0	1	04	01	H1418_007_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1418	007	0	1	04	01	H1418_007_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1418	007	0	1	04	01	H1418_007_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1418	007	0	1	04	01	H1418_007_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1418	007	0	1	04	01	H1418_007_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1419	001	0	1	01	01	H1419_001_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H1419	001	0	1	01	01	H1419_001_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H1419	001	0	1	01	01	H1419_001_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H1419	001	0	1	01	01	H1419_001_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
H1419	001	0	1	01	01	H1419_001_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1419	002	0	1	01	01	H1419_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H1419	002	0	1	01	01	H1419_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H1419	002	0	1	01	01	H1419_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H1419	002	0	1	01	01	H1419_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H1419	002	0	1	01	01	H1419_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1419	003	0	1	01	01	H1419_003_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H1419	003	0	1	01	01	H1419_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H1419	003	0	1	01	01	H1419_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H1419	003	0	1	01	01	H1419_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H1419	003	0	1	01	01	H1419_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1419	005	0	1	01	01	H1419_005_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H1419	005	0	1	01	01	H1419_005_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H1419	005	0	1	01	01	H1419_005_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	14.00	42.00									14.00					28.00			42.00		14.00
H1419	005	0	1	01	01	H1419_005_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1419	005	0	1	01	01	H1419_005_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H1420	001	0	1	04	01	H1420_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H1420	001	0	1	04	01	H1420_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H1420	001	0	1	04	01	H1420_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H1420	001	0	1	04	01	H1420_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H1420	001	0	1	04	01	H1420_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H1420	003	0	1	04	01	H1420_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H1420	003	0	1	04	01	H1420_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H1420	003	0	1	04	01	H1420_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H1420	003	0	1	04	01	H1420_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H1420	003	0	1	04	01	H1420_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H1463	003	0	1	01	01	H1463_003_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1463	003	0	1	01	01	H1463_003_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1463	003	0	1	01	01	H1463_003_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1463	003	0	1	01	01	H1463_003_0	7	4	3	1	Tier 4	000010		1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1463	005	0	1	01	01	H1463_005_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1463	005	0	1	01	01	H1463_005_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1463	005	0	1	01	01	H1463_005_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1463	005	0	1	01	01	H1463_005_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010100000000	30									30		30									31	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H1463	005	0	1	01	01	H1463_005_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	1	2	Tier 3																						Tier 3	76.00	228.00								76.00		76.00	228.00								76.00
H1463	005	0	1	01	01	H1463_005_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1463	005	0	1	01	01	H1463_005_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00
H1463	005	0	1	01	01	H1463_005_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	1	2	Tier 2																						Tier 2	36.00	108.00								36.00		36.00	108.00								36.00
H1468	004	0	1	01	01	H1468_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1468	004	0	1	01	01	H1468_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1468	004	0	1	01	01	H1468_004_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1468	004	0	1	01	01	H1468_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1468	004	0	1	01	01	H1468_004_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1468	004	0	1	01	01	H1468_004_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1468	004	0	1	01	01	H1468_004_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1468	004	0	1	01	01	H1468_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1468	007	0	1	01	01	H1468_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1468	007	0	1	01	01	H1468_007_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1468	007	0	1	01	01	H1468_007_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1468	007	0	1	01	01	H1468_007_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1468	007	0	1	01	01	H1468_007_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1468	007	0	1	01	01	H1468_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1468	007	0	1	01	01	H1468_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1468	007	0	1	01	01	H1468_007_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1509	001	0	1	04	01	H1509_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1509	001	0	1	04	01	H1509_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1509	001	0	1	04	01	H1509_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1509	001	0	1	04	01	H1509_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1509	005	0	1	04	01	H1509_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1509	005	0	1	04	01	H1509_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1509	005	0	1	04	01	H1509_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1509	005	0	1	04	01	H1509_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1509	006	0	1	04	01	H1509_006_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1509	006	0	1	04	01	H1509_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H1509	006	0	1	04	01	H1509_006_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1509	006	0	1	04	01	H1509_006_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H1509	007	0	1	04	01	H1509_007_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1509	007	0	1	04	01	H1509_007_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1509	007	0	1	04	01	H1509_007_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1509	007	0	1	04	01	H1509_007_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1509	008	0	1	04	01	H1509_008_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1509	008	0	1	04	01	H1509_008_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1509	008	0	1	04	01	H1509_008_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1509	008	0	1	04	01	H1509_008_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1510	001	0	1	04	01	H1510_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1510	001	0	1	04	01	H1510_001_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	001	0	1	04	01	H1510_001_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	001	0	1	04	01	H1510_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	001	0	1	04	01	H1510_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1510	001	0	1	04	01	H1510_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	001	0	1	04	01	H1510_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	001	0	1	04	01	H1510_001_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	004	0	1	04	01	H1510_004_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	004	0	1	04	01	H1510_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	004	0	1	04	01	H1510_004_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1510	004	0	1	04	01	H1510_004_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	004	0	1	04	01	H1510_004_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	004	0	1	04	01	H1510_004_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1510	004	0	1	04	01	H1510_004_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	004	0	1	04	01	H1510_004_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	005	0	1	04	01	H1510_005_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	005	0	1	04	01	H1510_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	005	0	1	04	01	H1510_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1510	005	0	1	04	01	H1510_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	005	0	1	04	01	H1510_005_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1510	005	0	1	04	01	H1510_005_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1510	005	0	1	04	01	H1510_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1510	005	0	1	04	01	H1510_005_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1511	001	0	1	01	01	H1511_001_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1511	001	0	1	01	01	H1511_001_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1511	001	0	1	01	01	H1511_001_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1511	001	0	1	01	01	H1511_001_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H1511	001	0	1	01	01	H1511_001_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1511	001	0	1	01	01	H1511_001_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1511	001	0	1	01	01	H1511_001_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H1511	001	0	1	01	01	H1511_001_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1511	001	0	1	01	01	H1511_001_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1511	001	0	1	01	01	H1511_001_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1511	005	0	1	01	01	H1511_005_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1511	005	0	1	01	01	H1511_005_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1511	005	0	1	01	01	H1511_005_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1511	005	0	1	01	01	H1511_005_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H1511	005	0	1	01	01	H1511_005_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1511	005	0	1	01	01	H1511_005_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1511	005	0	1	01	01	H1511_005_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1511	005	0	1	01	01	H1511_005_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1511	005	0	1	01	01	H1511_005_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H1511	005	0	1	01	01	H1511_005_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1517	001	0	1	04	01	H1517_001_0	9	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H1517	001	0	1	04	01	H1517_001_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1517	001	0	1	04	01	H1517_001_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1517	001	0	1	04	01	H1517_001_0	9	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
H1517	001	0	1	04	01	H1517_001_0	9	5	4	3	Tier 5 Speciality	010010	1	1	2			Tier 5 Speciality																							Tier 5 Speciality			Tier 5 Speciality																						Tier 5 Speciality																					
H1517	001	0	1	04	01	H1517_001_0	9	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H1517	001	0	1	04	01	H1517_001_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1517	001	0	1	04	01	H1517_001_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1517	001	0	1	04	01	H1517_001_0	9	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
H1517	001	0	1	04	01	H1517_001_0	9	5	4	1	Tier 5 Speciality	010010	1	1				Tier 5 Speciality	110000000010000100100	30									30				30			30				34	Tier 5 Speciality	2	1	Tier 5 Speciality	33									33					33			33			33	Tier 5 Speciality																					
H1607	001	0	1	04	01	H1607_001_0	10	1	4	1	Tier 1 Preferred Generics	001000	3	2				Tier 1 Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H1607	001	0	1	04	01	H1607_001_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1607	001	0	1	04	01	H1607_001_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1607	001	0	1	04	01	H1607_001_0	10	4	4	3	Tier 4 Non- Specialty Injectable	010010	1	2	2			Tier 4 Non- Specialty Injectable																							Tier 4 Non- Specialty Injectable			Tier 4 Non- Specialty Injectable																						Tier 4 Non- Specialty Injectable																					
H1607	001	0	1	04	01	H1607_001_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1607	001	0	1	04	01	H1607_001_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1607	001	0	1	04	01	H1607_001_0	10	1	4	3	Tier 1 Preferred Generics	001000	3	2	1		1	Tier 1 Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H1607	001	0	1	04	01	H1607_001_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1607	001	0	1	04	01	H1607_001_0	10	4	4	1	Tier 4 Non- Specialty Injectable	010010	1	2				Tier 4 Non- Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non- Specialty Injectable	2	1	Tier 4 Non- Specialty Injectable	33	33								33						33			33		33	Tier 4 Non- Specialty Injectable																					
H1607	001	0	1	04	01	H1607_001_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1608	001	0	1	04	01	H1608_001_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1608	001	0	1	04	01	H1608_001_0	12	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1608	001	0	1	04	01	H1608_001_0	12	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1608	001	0	1	04	01	H1608_001_0	12	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1608	001	0	1	04	01	H1608_001_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1608	001	0	1	04	01	H1608_001_0	12	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1608	001	0	1	04	01	H1608_001_0	12	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1608	001	0	1	04	01	H1608_001_0	12	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1608	002	0	1	04	01	H1608_002_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1608	002	0	1	04	01	H1608_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1608	002	0	1	04	01	H1608_002_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1608	002	0	1	04	01	H1608_002_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1608	002	0	1	04	01	H1608_002_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1608	002	0	1	04	01	H1608_002_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1608	002	0	1	04	01	H1608_002_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1608	002	0	1	04	01	H1608_002_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1608	003	0	1	04	01	H1608_003_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H1608	003	0	1	04	01	H1608_003_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1608	003	0	1	04	01	H1608_003_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H1608	003	0	1	04	01	H1608_003_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1608	003	0	1	04	01	H1608_003_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1608	003	0	1	04	01	H1608_003_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1608	003	0	1	04	01	H1608_003_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1608	003	0	1	04	01	H1608_003_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	001	0	1	01	01	H1609_001_0	11	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	001	0	1	01	01	H1609_001_0	11	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	001	0	1	01	01	H1609_001_0	11	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	001	0	1	01	01	H1609_001_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	001	0	1	01	01	H1609_001_0	11	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1609	001	0	1	01	01	H1609_001_0	11	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1609	001	0	1	01	01	H1609_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1609	001	0	1	01	01	H1609_001_0	11	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	003	0	1	01	01	H1609_003_0	13	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	003	0	1	01	01	H1609_003_0	13	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	003	0	1	01	01	H1609_003_0	13	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	003	0	1	01	01	H1609_003_0	13	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1609	003	0	1	01	01	H1609_003_0	13	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1609	003	0	1	01	01	H1609_003_0	13	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1609	003	0	1	01	01	H1609_003_0	13	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	003	0	1	01	01	H1609_003_0	13	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	004	0	1	01	01	H1609_004_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	004	0	1	01	01	H1609_004_0	11	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	004	0	1	01	01	H1609_004_0	11	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	004	0	1	01	01	H1609_004_0	11	5	4	3	Other - Special Needs	001001	1	2	1		1	Other - Special Needs	111000000010010000000	30	90								30										90	31	Other - Special Needs	2	2	Other - Special Needs																						Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H1609	004	0	1	01	01	H1609_004_0	11	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	004	0	1	01	01	H1609_004_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1609	004	0	1	01	01	H1609_004_0	11	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1609	004	0	1	01	01	H1609_004_0	11	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1609	004	0	1	01	01	H1609_004_0	11	5	4	1	Other - Special Needs	001001	1	2				Other - Special Needs	111000000010010000000	30	90								30										90	31	Other - Special Needs	2	2	Other - Special Needs																						Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H1609	004	0	1	01	01	H1609_004_0	11	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	005	0	1	01	01	H1609_005_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	005	0	1	01	01	H1609_005_0	12	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	005	0	1	01	01	H1609_005_0	12	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	005	0	1	01	01	H1609_005_0	12	5	4	3	Other - Special Needs	001001	1	2	1		1	Other - Special Needs	111000000010010000000	30	90								30										90	31	Other - Special Needs	2	2	Other - Special Needs																						Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H1609	005	0	1	01	01	H1609_005_0	12	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	005	0	1	01	01	H1609_005_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
H1609	005	0	1	01	01	H1609_005_0	12	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H1609	005	0	1	01	01	H1609_005_0	12	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1609	005	0	1	01	01	H1609_005_0	12	5	4	1	Other - Special Needs	001001	1	2				Other - Special Needs	111000000010010000000	30	90								30										90	31	Other - Special Needs	2	2	Other - Special Needs																						Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H1609	005	0	1	01	01	H1609_005_0	12	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H1609	006	0	1	01	01	H1609_006_0	12	4	3	1	Specialty - Generic and Brand	010010		1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																					
H1609	006	0	1	01	01	H1609_006_0	12	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00											62.00
H1609	006	0	1	01	01	H1609_006_0	12	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00											32.00
H1609	006	0	1	01	01	H1609_006_0	12	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00											5.00
H1609	007	0	1	01	01	H1609_007_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	007	0	1	01	01	H1609_007_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	007	0	1	01	01	H1609_007_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	007	0	1	01	01	H1609_007_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1609	007	0	1	01	01	H1609_007_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H1609	007	0	1	01	01	H1609_007_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1609	007	0	1	01	01	H1609_007_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1609	007	0	1	01	01	H1609_007_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H1609	008	0	1	01	01	H1609_008_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H1609	008	0	1	01	01	H1609_008_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H1609	008	0	1	01	01	H1609_008_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H1609	008	0	1	01	01	H1609_008_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1609	008	0	1	01	01	H1609_008_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H1609	008	0	1	01	01	H1609_008_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1609	008	0	1	01	01	H1609_008_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H1609	008	0	1	01	01	H1609_008_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H1643	001	0	1	09	04	H1643_001_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H1643	001	0	1	09	04	H1643_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H1643	001	0	1	09	04	H1643_001_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H1643	001	0	1	09	04	H1643_001_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1643	003	0	1	09	04	H1643_003_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H1643	003	0	1	09	04	H1643_003_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00		72.50	72.50								29.00
H1643	003	0	1	09	04	H1643_003_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H1643	003	0	1	09	04	H1643_003_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1643	003	0	1	09	04	H1643_003_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H1643	003	0	1	09	04	H1643_003_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1643	003	0	1	09	04	H1643_003_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1643	003	0	1	09	04	H1643_003_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1643	004	0	1	09	04	H1643_004_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H1643	004	0	1	09	04	H1643_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H1643	004	0	1	09	04	H1643_004_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1643	004	0	1	09	04	H1643_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H1643	006	0	1	09	04	H1643_006_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H1643	006	0	1	09	04	H1643_006_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00		72.50	72.50								29.00
H1643	006	0	1	09	04	H1643_006_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H1643	006	0	1	09	04	H1643_006_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H1643	006	0	1	09	04	H1643_006_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H1643	006	0	1	09	04	H1643_006_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1643	006	0	1	09	04	H1643_006_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1643	006	0	1	09	04	H1643_006_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1657	002	0	1	02	01	H1657_002_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1657	002	0	1	02	01	H1657_002_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1657	002	0	1	02	01	H1657_002_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H1657	002	0	1	02	01	H1657_002_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	003	0	1	02	01	H1657_003_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H1657	003	0	1	02	01	H1657_003_0	7	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1657	003	0	1	02	01	H1657_003_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	003	0	1	02	01	H1657_003_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1657	003	0	1	02	01	H1657_003_0	7	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1657	003	0	1	02	01	H1657_003_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1657	003	0	1	02	01	H1657_003_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1657	003	0	1	02	01	H1657_003_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	004	0	1	01	01	H1657_004_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1657	004	0	1	01	01	H1657_004_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1657	004	0	1	01	01	H1657_004_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1657	004	0	1	01	01	H1657_004_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	005	0	1	02	01	H1657_005_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	005	0	1	02	01	H1657_005_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1657	005	0	1	02	01	H1657_005_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1657	005	0	1	02	01	H1657_005_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1657	006	0	1	02	01	H1657_006_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1657	006	0	1	02	01	H1657_006_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
H1657	006	0	1	02	01	H1657_006_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	006	0	1	02	01	H1657_006_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
H1657	007	0	1	02	01	H1657_007_0	7	1	4	3	Tier 1	010000	1	2	2			Tier 1																							Tier 1			Tier 1																						Tier 1																					
H1657	007	0	1	02	01	H1657_007_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1657	007	0	1	02	01	H1657_007_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1657	007	0	1	02	01	H1657_007_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1657	007	0	1	02	01	H1657_007_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	007	0	1	02	01	H1657_007_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H1657	007	0	1	02	01	H1657_007_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H1657	007	0	1	02	01	H1657_007_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1657	008	0	1	02	01	H1657_008_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1657	008	0	1	02	01	H1657_008_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	008	0	1	02	01	H1657_008_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00
H1657	008	0	1	02	01	H1657_008_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	35.00	105.00								35.00			105.00								35.00
H1657	008	0	1	02	01	H1657_008_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1657	008	0	1	02	01	H1657_008_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	008	0	1	02	01	H1657_008_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1657	008	0	1	02	01	H1657_008_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1657	009	0	1	02	01	H1657_009_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00
H1657	009	0	1	02	01	H1657_009_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	35.00	105.00								35.00			105.00								35.00
H1657	009	0	1	02	01	H1657_009_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1657	009	0	1	02	01	H1657_009_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	009	0	1	02	01	H1657_009_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1657	009	0	1	02	01	H1657_009_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1657	009	0	1	02	01	H1657_009_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1657	009	0	1	02	01	H1657_009_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1681	001	0	1	04	01	H1681_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	001	0	1	04	01	H1681_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	001	0	1	04	01	H1681_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	001	0	1	04	01	H1681_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1681	001	0	1	04	01	H1681_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	001	0	1	04	01	H1681_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	001	0	1	04	01	H1681_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	001	0	1	04	01	H1681_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1681	002	0	1	04	01	H1681_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	002	0	1	04	01	H1681_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	002	0	1	04	01	H1681_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1681	002	0	1	04	01	H1681_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	002	0	1	04	01	H1681_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	002	0	1	04	01	H1681_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1681	002	0	1	04	01	H1681_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	002	0	1	04	01	H1681_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	003	0	1	04	01	H1681_003_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	003	0	1	04	01	H1681_003_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	003	0	1	04	01	H1681_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1681	003	0	1	04	01	H1681_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	003	0	1	04	01	H1681_003_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1681	003	0	1	04	01	H1681_003_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1681	003	0	1	04	01	H1681_003_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1681	003	0	1	04	01	H1681_003_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1689	013	0	1	09	04	H1689_013_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1689	013	0	1	09	04	H1689_013_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1689	013	0	1	09	04	H1689_013_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1689	013	0	1	09	04	H1689_013_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H1689	013	0	1	09	04	H1689_013_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1689	013	0	1	09	04	H1689_013_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1689	013	0	1	09	04	H1689_013_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H1689	013	0	1	09	04	H1689_013_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1689	013	0	1	09	04	H1689_013_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1689	013	0	1	09	04	H1689_013_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1716	001	0	1	04	01	H1716_001_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	001	0	1	04	01	H1716_001_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	001	0	1	04	01	H1716_001_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	001	0	1	04	01	H1716_001_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	001	0	1	04	01	H1716_001_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	001	0	1	04	01	H1716_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	001	0	1	04	01	H1716_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	001	0	1	04	01	H1716_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	002	0	1	04	01	H1716_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	002	0	1	04	01	H1716_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	002	0	1	04	01	H1716_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	002	0	1	04	01	H1716_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	002	0	1	04	01	H1716_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	002	0	1	04	01	H1716_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	002	0	1	04	01	H1716_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	002	0	1	04	01	H1716_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	004	0	1	04	01	H1716_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	004	0	1	04	01	H1716_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	004	0	1	04	01	H1716_004_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	004	0	1	04	01	H1716_004_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	004	0	1	04	01	H1716_004_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	004	0	1	04	01	H1716_004_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	004	0	1	04	01	H1716_004_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	004	0	1	04	01	H1716_004_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	006	0	1	04	01	H1716_006_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	006	0	1	04	01	H1716_006_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	006	0	1	04	01	H1716_006_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	006	0	1	04	01	H1716_006_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	006	0	1	04	01	H1716_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	006	0	1	04	01	H1716_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	006	0	1	04	01	H1716_006_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	006	0	1	04	01	H1716_006_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	009	0	1	04	01	H1716_009_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	009	0	1	04	01	H1716_009_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	009	0	1	04	01	H1716_009_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	009	0	1	04	01	H1716_009_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	009	0	1	04	01	H1716_009_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	009	0	1	04	01	H1716_009_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1716	009	0	1	04	01	H1716_009_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	009	0	1	04	01	H1716_009_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H1716	010	0	1	04	01	H1716_010_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1716	010	0	1	04	01	H1716_010_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1716	010	0	1	04	01	H1716_010_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1716	010	0	1	04	01	H1716_010_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	010	0	1	04	01	H1716_010_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1716	010	0	1	04	01	H1716_010_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1716	010	0	1	04	01	H1716_010_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1716	010	0	1	04	01	H1716_010_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1717	001	0	1	04	01	H1717_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1717	001	0	1	04	01	H1717_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1717	001	0	1	04	01	H1717_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1717	001	0	1	04	01	H1717_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1717	008	0	1	04	01	H1717_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1717	008	0	1	04	01	H1717_008_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1717	008	0	1	04	01	H1717_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1717	008	0	1	04	01	H1717_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1717	009	0	1	04	01	H1717_009_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1717	009	0	1	04	01	H1717_009_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H1717	009	0	1	04	01	H1717_009_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H1717	009	0	1	04	01	H1717_009_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1717	010	0	1	04	01	H1717_010_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1717	010	0	1	04	01	H1717_010_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H1717	010	0	1	04	01	H1717_010_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H1717	010	0	1	04	01	H1717_010_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1804	001	0	1	09	04	H1804_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	001	0	1	09	04	H1804_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	001	0	1	09	04	H1804_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	001	0	1	09	04	H1804_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	001	0	1	09	04	H1804_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	001	0	1	09	04	H1804_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	001	0	1	09	04	H1804_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	001	0	1	09	04	H1804_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	005	0	1	09	04	H1804_005_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	005	0	1	09	04	H1804_005_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	005	0	1	09	04	H1804_005_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	005	0	1	09	04	H1804_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	005	0	1	09	04	H1804_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	005	0	1	09	04	H1804_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	005	0	1	09	04	H1804_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	005	0	1	09	04	H1804_005_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	006	0	1	09	04	H1804_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	006	0	1	09	04	H1804_006_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	006	0	1	09	04	H1804_006_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	006	0	1	09	04	H1804_006_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	006	0	1	09	04	H1804_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	006	0	1	09	04	H1804_006_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	006	0	1	09	04	H1804_006_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	006	0	1	09	04	H1804_006_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	007	0	1	09	04	H1804_007_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	007	0	1	09	04	H1804_007_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	007	0	1	09	04	H1804_007_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	007	0	1	09	04	H1804_007_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	007	0	1	09	04	H1804_007_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	007	0	1	09	04	H1804_007_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	007	0	1	09	04	H1804_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	007	0	1	09	04	H1804_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	008	0	1	09	04	H1804_008_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	008	0	1	09	04	H1804_008_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	008	0	1	09	04	H1804_008_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	008	0	1	09	04	H1804_008_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	008	0	1	09	04	H1804_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	008	0	1	09	04	H1804_008_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	008	0	1	09	04	H1804_008_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	008	0	1	09	04	H1804_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	009	0	1	09	04	H1804_009_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	009	0	1	09	04	H1804_009_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	009	0	1	09	04	H1804_009_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	009	0	1	09	04	H1804_009_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	009	0	1	09	04	H1804_009_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	009	0	1	09	04	H1804_009_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	009	0	1	09	04	H1804_009_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	009	0	1	09	04	H1804_009_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	011	0	1	09	04	H1804_011_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	011	0	1	09	04	H1804_011_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	011	0	1	09	04	H1804_011_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	011	0	1	09	04	H1804_011_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	011	0	1	09	04	H1804_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	011	0	1	09	04	H1804_011_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	011	0	1	09	04	H1804_011_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	011	0	1	09	04	H1804_011_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	013	0	1	09	04	H1804_013_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	013	0	1	09	04	H1804_013_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	013	0	1	09	04	H1804_013_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	013	0	1	09	04	H1804_013_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	013	0	1	09	04	H1804_013_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	013	0	1	09	04	H1804_013_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	013	0	1	09	04	H1804_013_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	013	0	1	09	04	H1804_013_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	014	0	1	09	04	H1804_014_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	014	0	1	09	04	H1804_014_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	014	0	1	09	04	H1804_014_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	014	0	1	09	04	H1804_014_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	014	0	1	09	04	H1804_014_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	014	0	1	09	04	H1804_014_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	014	0	1	09	04	H1804_014_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	014	0	1	09	04	H1804_014_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	016	0	1	09	04	H1804_016_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	016	0	1	09	04	H1804_016_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	016	0	1	09	04	H1804_016_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	016	0	1	09	04	H1804_016_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	016	0	1	09	04	H1804_016_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	016	0	1	09	04	H1804_016_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	016	0	1	09	04	H1804_016_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	016	0	1	09	04	H1804_016_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	018	0	1	09	04	H1804_018_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	018	0	1	09	04	H1804_018_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	018	0	1	09	04	H1804_018_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	018	0	1	09	04	H1804_018_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	018	0	1	09	04	H1804_018_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	018	0	1	09	04	H1804_018_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	018	0	1	09	04	H1804_018_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	018	0	1	09	04	H1804_018_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	019	0	1	09	04	H1804_019_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	019	0	1	09	04	H1804_019_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	019	0	1	09	04	H1804_019_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	019	0	1	09	04	H1804_019_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	019	0	1	09	04	H1804_019_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	019	0	1	09	04	H1804_019_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	019	0	1	09	04	H1804_019_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	019	0	1	09	04	H1804_019_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	020	0	1	09	04	H1804_020_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	020	0	1	09	04	H1804_020_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	020	0	1	09	04	H1804_020_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	020	0	1	09	04	H1804_020_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	020	0	1	09	04	H1804_020_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	020	0	1	09	04	H1804_020_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	020	0	1	09	04	H1804_020_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	020	0	1	09	04	H1804_020_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	022	0	1	09	04	H1804_022_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	022	0	1	09	04	H1804_022_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	022	0	1	09	04	H1804_022_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	022	0	1	09	04	H1804_022_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	022	0	1	09	04	H1804_022_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	022	0	1	09	04	H1804_022_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	022	0	1	09	04	H1804_022_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	022	0	1	09	04	H1804_022_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	023	0	1	09	04	H1804_023_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	023	0	1	09	04	H1804_023_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	023	0	1	09	04	H1804_023_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	023	0	1	09	04	H1804_023_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	023	0	1	09	04	H1804_023_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	023	0	1	09	04	H1804_023_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	023	0	1	09	04	H1804_023_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	023	0	1	09	04	H1804_023_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	025	0	1	09	04	H1804_025_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	025	0	1	09	04	H1804_025_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	025	0	1	09	04	H1804_025_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	025	0	1	09	04	H1804_025_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	025	0	1	09	04	H1804_025_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	025	0	1	09	04	H1804_025_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	025	0	1	09	04	H1804_025_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	025	0	1	09	04	H1804_025_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	061	0	1	09	04	H1804_061_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	061	0	1	09	04	H1804_061_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	061	0	1	09	04	H1804_061_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	061	0	1	09	04	H1804_061_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	061	0	1	09	04	H1804_061_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	061	0	1	09	04	H1804_061_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	061	0	1	09	04	H1804_061_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	061	0	1	09	04	H1804_061_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	063	0	1	09	04	H1804_063_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	063	0	1	09	04	H1804_063_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	063	0	1	09	04	H1804_063_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	063	0	1	09	04	H1804_063_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	063	0	1	09	04	H1804_063_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	063	0	1	09	04	H1804_063_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	063	0	1	09	04	H1804_063_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	063	0	1	09	04	H1804_063_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	066	0	1	09	04	H1804_066_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	066	0	1	09	04	H1804_066_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	066	0	1	09	04	H1804_066_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	066	0	1	09	04	H1804_066_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	066	0	1	09	04	H1804_066_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	066	0	1	09	04	H1804_066_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	066	0	1	09	04	H1804_066_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	066	0	1	09	04	H1804_066_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	067	0	1	09	04	H1804_067_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	067	0	1	09	04	H1804_067_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	067	0	1	09	04	H1804_067_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	067	0	1	09	04	H1804_067_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	067	0	1	09	04	H1804_067_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	067	0	1	09	04	H1804_067_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	067	0	1	09	04	H1804_067_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	067	0	1	09	04	H1804_067_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	068	0	1	09	04	H1804_068_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	068	0	1	09	04	H1804_068_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	068	0	1	09	04	H1804_068_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	068	0	1	09	04	H1804_068_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	068	0	1	09	04	H1804_068_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	068	0	1	09	04	H1804_068_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	068	0	1	09	04	H1804_068_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	068	0	1	09	04	H1804_068_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	075	0	1	09	04	H1804_075_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	075	0	1	09	04	H1804_075_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	075	0	1	09	04	H1804_075_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	075	0	1	09	04	H1804_075_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	075	0	1	09	04	H1804_075_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	075	0	1	09	04	H1804_075_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	075	0	1	09	04	H1804_075_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	075	0	1	09	04	H1804_075_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	077	0	1	09	04	H1804_077_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	077	0	1	09	04	H1804_077_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	077	0	1	09	04	H1804_077_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	077	0	1	09	04	H1804_077_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	077	0	1	09	04	H1804_077_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	077	0	1	09	04	H1804_077_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	077	0	1	09	04	H1804_077_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	077	0	1	09	04	H1804_077_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	081	0	1	09	04	H1804_081_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	081	0	1	09	04	H1804_081_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	081	0	1	09	04	H1804_081_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	081	0	1	09	04	H1804_081_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	081	0	1	09	04	H1804_081_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	081	0	1	09	04	H1804_081_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	081	0	1	09	04	H1804_081_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	081	0	1	09	04	H1804_081_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	086	0	1	09	04	H1804_086_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	086	0	1	09	04	H1804_086_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	086	0	1	09	04	H1804_086_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	086	0	1	09	04	H1804_086_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	086	0	1	09	04	H1804_086_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	086	0	1	09	04	H1804_086_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	086	0	1	09	04	H1804_086_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	086	0	1	09	04	H1804_086_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	087	0	1	09	04	H1804_087_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	087	0	1	09	04	H1804_087_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	087	0	1	09	04	H1804_087_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	087	0	1	09	04	H1804_087_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	087	0	1	09	04	H1804_087_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	087	0	1	09	04	H1804_087_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	087	0	1	09	04	H1804_087_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	087	0	1	09	04	H1804_087_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	089	0	1	09	04	H1804_089_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	089	0	1	09	04	H1804_089_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	089	0	1	09	04	H1804_089_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	089	0	1	09	04	H1804_089_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	089	0	1	09	04	H1804_089_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	089	0	1	09	04	H1804_089_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	089	0	1	09	04	H1804_089_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	089	0	1	09	04	H1804_089_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	090	0	1	09	04	H1804_090_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	090	0	1	09	04	H1804_090_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	090	0	1	09	04	H1804_090_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	090	0	1	09	04	H1804_090_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	090	0	1	09	04	H1804_090_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	090	0	1	09	04	H1804_090_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	090	0	1	09	04	H1804_090_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	090	0	1	09	04	H1804_090_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	091	0	1	09	04	H1804_091_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	091	0	1	09	04	H1804_091_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	091	0	1	09	04	H1804_091_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	091	0	1	09	04	H1804_091_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	091	0	1	09	04	H1804_091_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	091	0	1	09	04	H1804_091_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	091	0	1	09	04	H1804_091_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	091	0	1	09	04	H1804_091_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	093	0	1	09	04	H1804_093_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	093	0	1	09	04	H1804_093_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	093	0	1	09	04	H1804_093_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	093	0	1	09	04	H1804_093_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	093	0	1	09	04	H1804_093_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	093	0	1	09	04	H1804_093_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	093	0	1	09	04	H1804_093_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	093	0	1	09	04	H1804_093_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	094	0	1	09	04	H1804_094_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	094	0	1	09	04	H1804_094_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	094	0	1	09	04	H1804_094_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	094	0	1	09	04	H1804_094_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	094	0	1	09	04	H1804_094_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	094	0	1	09	04	H1804_094_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	094	0	1	09	04	H1804_094_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	094	0	1	09	04	H1804_094_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	095	0	1	09	04	H1804_095_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	095	0	1	09	04	H1804_095_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	095	0	1	09	04	H1804_095_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	095	0	1	09	04	H1804_095_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	095	0	1	09	04	H1804_095_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	095	0	1	09	04	H1804_095_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	095	0	1	09	04	H1804_095_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	095	0	1	09	04	H1804_095_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	097	0	1	09	04	H1804_097_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	097	0	1	09	04	H1804_097_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	097	0	1	09	04	H1804_097_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	097	0	1	09	04	H1804_097_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	097	0	1	09	04	H1804_097_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	097	0	1	09	04	H1804_097_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	097	0	1	09	04	H1804_097_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	097	0	1	09	04	H1804_097_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	098	0	1	09	04	H1804_098_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	098	0	1	09	04	H1804_098_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	098	0	1	09	04	H1804_098_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	098	0	1	09	04	H1804_098_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	098	0	1	09	04	H1804_098_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	098	0	1	09	04	H1804_098_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	098	0	1	09	04	H1804_098_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	098	0	1	09	04	H1804_098_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	103	0	1	09	04	H1804_103_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	103	0	1	09	04	H1804_103_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	103	0	1	09	04	H1804_103_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	103	0	1	09	04	H1804_103_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	103	0	1	09	04	H1804_103_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	103	0	1	09	04	H1804_103_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	103	0	1	09	04	H1804_103_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	103	0	1	09	04	H1804_103_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	122	0	1	09	04	H1804_122_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	122	0	1	09	04	H1804_122_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	122	0	1	09	04	H1804_122_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	122	0	1	09	04	H1804_122_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	122	0	1	09	04	H1804_122_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	122	0	1	09	04	H1804_122_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	122	0	1	09	04	H1804_122_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	122	0	1	09	04	H1804_122_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	125	0	1	09	04	H1804_125_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	125	0	1	09	04	H1804_125_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	125	0	1	09	04	H1804_125_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	125	0	1	09	04	H1804_125_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	125	0	1	09	04	H1804_125_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	125	0	1	09	04	H1804_125_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	125	0	1	09	04	H1804_125_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	125	0	1	09	04	H1804_125_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	126	0	1	09	04	H1804_126_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	126	0	1	09	04	H1804_126_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	126	0	1	09	04	H1804_126_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	126	0	1	09	04	H1804_126_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	126	0	1	09	04	H1804_126_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	126	0	1	09	04	H1804_126_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	126	0	1	09	04	H1804_126_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	126	0	1	09	04	H1804_126_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	127	0	1	09	04	H1804_127_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	127	0	1	09	04	H1804_127_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	127	0	1	09	04	H1804_127_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	127	0	1	09	04	H1804_127_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	127	0	1	09	04	H1804_127_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	127	0	1	09	04	H1804_127_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	127	0	1	09	04	H1804_127_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	127	0	1	09	04	H1804_127_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	128	0	1	09	04	H1804_128_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	128	0	1	09	04	H1804_128_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	128	0	1	09	04	H1804_128_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	128	0	1	09	04	H1804_128_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	128	0	1	09	04	H1804_128_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	128	0	1	09	04	H1804_128_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	128	0	1	09	04	H1804_128_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	128	0	1	09	04	H1804_128_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	129	0	1	09	04	H1804_129_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	129	0	1	09	04	H1804_129_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	129	0	1	09	04	H1804_129_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	129	0	1	09	04	H1804_129_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	129	0	1	09	04	H1804_129_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	129	0	1	09	04	H1804_129_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	129	0	1	09	04	H1804_129_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	129	0	1	09	04	H1804_129_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	130	0	1	09	04	H1804_130_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	130	0	1	09	04	H1804_130_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	130	0	1	09	04	H1804_130_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	130	0	1	09	04	H1804_130_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	130	0	1	09	04	H1804_130_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	130	0	1	09	04	H1804_130_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	130	0	1	09	04	H1804_130_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	130	0	1	09	04	H1804_130_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	131	0	1	09	04	H1804_131_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	131	0	1	09	04	H1804_131_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	131	0	1	09	04	H1804_131_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	131	0	1	09	04	H1804_131_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	131	0	1	09	04	H1804_131_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	131	0	1	09	04	H1804_131_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	131	0	1	09	04	H1804_131_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	131	0	1	09	04	H1804_131_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	132	0	1	09	04	H1804_132_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	132	0	1	09	04	H1804_132_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	132	0	1	09	04	H1804_132_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	132	0	1	09	04	H1804_132_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	132	0	1	09	04	H1804_132_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	132	0	1	09	04	H1804_132_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	132	0	1	09	04	H1804_132_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	132	0	1	09	04	H1804_132_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	133	0	1	09	04	H1804_133_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	133	0	1	09	04	H1804_133_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	133	0	1	09	04	H1804_133_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	133	0	1	09	04	H1804_133_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	133	0	1	09	04	H1804_133_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	133	0	1	09	04	H1804_133_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	133	0	1	09	04	H1804_133_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	133	0	1	09	04	H1804_133_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	137	0	1	09	04	H1804_137_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	137	0	1	09	04	H1804_137_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	137	0	1	09	04	H1804_137_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	137	0	1	09	04	H1804_137_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	137	0	1	09	04	H1804_137_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	137	0	1	09	04	H1804_137_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	137	0	1	09	04	H1804_137_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	137	0	1	09	04	H1804_137_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	138	0	1	09	04	H1804_138_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	138	0	1	09	04	H1804_138_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	138	0	1	09	04	H1804_138_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	138	0	1	09	04	H1804_138_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	138	0	1	09	04	H1804_138_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	138	0	1	09	04	H1804_138_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	138	0	1	09	04	H1804_138_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	138	0	1	09	04	H1804_138_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	145	0	1	09	04	H1804_145_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	145	0	1	09	04	H1804_145_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	145	0	1	09	04	H1804_145_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	145	0	1	09	04	H1804_145_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	145	0	1	09	04	H1804_145_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	145	0	1	09	04	H1804_145_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	145	0	1	09	04	H1804_145_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	145	0	1	09	04	H1804_145_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	146	0	1	09	04	H1804_146_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	146	0	1	09	04	H1804_146_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	146	0	1	09	04	H1804_146_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	146	0	1	09	04	H1804_146_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	146	0	1	09	04	H1804_146_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	146	0	1	09	04	H1804_146_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	146	0	1	09	04	H1804_146_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	146	0	1	09	04	H1804_146_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	147	0	1	09	04	H1804_147_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	147	0	1	09	04	H1804_147_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	147	0	1	09	04	H1804_147_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	147	0	1	09	04	H1804_147_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	147	0	1	09	04	H1804_147_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	147	0	1	09	04	H1804_147_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	147	0	1	09	04	H1804_147_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	147	0	1	09	04	H1804_147_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	153	0	1	09	04	H1804_153_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	153	0	1	09	04	H1804_153_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	153	0	1	09	04	H1804_153_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	153	0	1	09	04	H1804_153_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	153	0	1	09	04	H1804_153_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	153	0	1	09	04	H1804_153_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	153	0	1	09	04	H1804_153_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	153	0	1	09	04	H1804_153_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	154	0	1	09	04	H1804_154_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	154	0	1	09	04	H1804_154_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	154	0	1	09	04	H1804_154_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	154	0	1	09	04	H1804_154_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	154	0	1	09	04	H1804_154_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	154	0	1	09	04	H1804_154_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	154	0	1	09	04	H1804_154_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	154	0	1	09	04	H1804_154_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	155	0	1	09	04	H1804_155_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	155	0	1	09	04	H1804_155_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	155	0	1	09	04	H1804_155_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	155	0	1	09	04	H1804_155_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	155	0	1	09	04	H1804_155_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	155	0	1	09	04	H1804_155_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	155	0	1	09	04	H1804_155_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	155	0	1	09	04	H1804_155_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	156	0	1	09	04	H1804_156_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	156	0	1	09	04	H1804_156_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	156	0	1	09	04	H1804_156_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	156	0	1	09	04	H1804_156_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	156	0	1	09	04	H1804_156_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	156	0	1	09	04	H1804_156_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	156	0	1	09	04	H1804_156_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	156	0	1	09	04	H1804_156_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	157	0	1	09	04	H1804_157_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	157	0	1	09	04	H1804_157_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	157	0	1	09	04	H1804_157_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	157	0	1	09	04	H1804_157_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	157	0	1	09	04	H1804_157_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	157	0	1	09	04	H1804_157_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	157	0	1	09	04	H1804_157_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	157	0	1	09	04	H1804_157_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	161	0	1	09	04	H1804_161_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	161	0	1	09	04	H1804_161_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	161	0	1	09	04	H1804_161_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	161	0	1	09	04	H1804_161_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	161	0	1	09	04	H1804_161_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	161	0	1	09	04	H1804_161_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	161	0	1	09	04	H1804_161_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	161	0	1	09	04	H1804_161_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	162	0	1	09	04	H1804_162_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	162	0	1	09	04	H1804_162_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	162	0	1	09	04	H1804_162_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	162	0	1	09	04	H1804_162_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	162	0	1	09	04	H1804_162_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	162	0	1	09	04	H1804_162_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	162	0	1	09	04	H1804_162_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	162	0	1	09	04	H1804_162_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	163	0	1	09	04	H1804_163_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	163	0	1	09	04	H1804_163_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	163	0	1	09	04	H1804_163_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	163	0	1	09	04	H1804_163_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	163	0	1	09	04	H1804_163_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	163	0	1	09	04	H1804_163_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	163	0	1	09	04	H1804_163_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	163	0	1	09	04	H1804_163_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	165	0	1	09	04	H1804_165_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	165	0	1	09	04	H1804_165_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	165	0	1	09	04	H1804_165_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	165	0	1	09	04	H1804_165_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	165	0	1	09	04	H1804_165_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	165	0	1	09	04	H1804_165_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	165	0	1	09	04	H1804_165_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	165	0	1	09	04	H1804_165_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	166	0	1	09	04	H1804_166_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	166	0	1	09	04	H1804_166_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	166	0	1	09	04	H1804_166_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	166	0	1	09	04	H1804_166_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	166	0	1	09	04	H1804_166_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	166	0	1	09	04	H1804_166_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	166	0	1	09	04	H1804_166_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	166	0	1	09	04	H1804_166_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	167	0	1	09	04	H1804_167_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	167	0	1	09	04	H1804_167_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	167	0	1	09	04	H1804_167_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	167	0	1	09	04	H1804_167_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	167	0	1	09	04	H1804_167_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	167	0	1	09	04	H1804_167_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	167	0	1	09	04	H1804_167_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	167	0	1	09	04	H1804_167_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	168	0	1	09	04	H1804_168_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	168	0	1	09	04	H1804_168_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	168	0	1	09	04	H1804_168_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	168	0	1	09	04	H1804_168_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	168	0	1	09	04	H1804_168_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	168	0	1	09	04	H1804_168_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	168	0	1	09	04	H1804_168_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	168	0	1	09	04	H1804_168_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	169	0	1	09	04	H1804_169_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	169	0	1	09	04	H1804_169_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	169	0	1	09	04	H1804_169_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	169	0	1	09	04	H1804_169_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	169	0	1	09	04	H1804_169_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	169	0	1	09	04	H1804_169_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	169	0	1	09	04	H1804_169_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	169	0	1	09	04	H1804_169_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	170	0	1	09	04	H1804_170_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	170	0	1	09	04	H1804_170_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	170	0	1	09	04	H1804_170_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	170	0	1	09	04	H1804_170_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	170	0	1	09	04	H1804_170_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	170	0	1	09	04	H1804_170_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	170	0	1	09	04	H1804_170_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	170	0	1	09	04	H1804_170_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	171	0	1	09	04	H1804_171_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	171	0	1	09	04	H1804_171_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	171	0	1	09	04	H1804_171_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	171	0	1	09	04	H1804_171_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	171	0	1	09	04	H1804_171_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	171	0	1	09	04	H1804_171_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	171	0	1	09	04	H1804_171_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	171	0	1	09	04	H1804_171_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	172	0	1	09	04	H1804_172_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	172	0	1	09	04	H1804_172_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	172	0	1	09	04	H1804_172_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	172	0	1	09	04	H1804_172_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	172	0	1	09	04	H1804_172_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	172	0	1	09	04	H1804_172_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	172	0	1	09	04	H1804_172_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	172	0	1	09	04	H1804_172_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	173	0	1	09	04	H1804_173_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	173	0	1	09	04	H1804_173_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	173	0	1	09	04	H1804_173_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	173	0	1	09	04	H1804_173_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	173	0	1	09	04	H1804_173_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	173	0	1	09	04	H1804_173_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	173	0	1	09	04	H1804_173_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	173	0	1	09	04	H1804_173_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	174	0	1	09	04	H1804_174_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	174	0	1	09	04	H1804_174_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	174	0	1	09	04	H1804_174_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	174	0	1	09	04	H1804_174_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H1804	174	0	1	09	04	H1804_174_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	174	0	1	09	04	H1804_174_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	174	0	1	09	04	H1804_174_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	174	0	1	09	04	H1804_174_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H1804	175	0	1	09	04	H1804_175_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	175	0	1	09	04	H1804_175_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	175	0	1	09	04	H1804_175_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	175	0	1	09	04	H1804_175_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	175	0	1	09	04	H1804_175_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	175	0	1	09	04	H1804_175_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	175	0	1	09	04	H1804_175_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	175	0	1	09	04	H1804_175_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	176	0	1	09	04	H1804_176_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	176	0	1	09	04	H1804_176_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	176	0	1	09	04	H1804_176_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	176	0	1	09	04	H1804_176_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	176	0	1	09	04	H1804_176_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	176	0	1	09	04	H1804_176_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	176	0	1	09	04	H1804_176_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	176	0	1	09	04	H1804_176_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	177	0	1	09	04	H1804_177_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	177	0	1	09	04	H1804_177_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	177	0	1	09	04	H1804_177_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	177	0	1	09	04	H1804_177_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	177	0	1	09	04	H1804_177_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	177	0	1	09	04	H1804_177_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	177	0	1	09	04	H1804_177_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	177	0	1	09	04	H1804_177_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	178	0	1	09	04	H1804_178_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	178	0	1	09	04	H1804_178_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	178	0	1	09	04	H1804_178_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	178	0	1	09	04	H1804_178_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	178	0	1	09	04	H1804_178_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	178	0	1	09	04	H1804_178_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	178	0	1	09	04	H1804_178_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	178	0	1	09	04	H1804_178_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	180	0	1	09	04	H1804_180_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	180	0	1	09	04	H1804_180_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	180	0	1	09	04	H1804_180_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	180	0	1	09	04	H1804_180_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	180	0	1	09	04	H1804_180_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	180	0	1	09	04	H1804_180_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	180	0	1	09	04	H1804_180_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	180	0	1	09	04	H1804_180_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	181	0	1	09	04	H1804_181_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	181	0	1	09	04	H1804_181_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	181	0	1	09	04	H1804_181_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	181	0	1	09	04	H1804_181_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	181	0	1	09	04	H1804_181_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	181	0	1	09	04	H1804_181_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	181	0	1	09	04	H1804_181_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	181	0	1	09	04	H1804_181_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	184	0	1	09	04	H1804_184_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	184	0	1	09	04	H1804_184_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	184	0	1	09	04	H1804_184_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	184	0	1	09	04	H1804_184_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	184	0	1	09	04	H1804_184_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	184	0	1	09	04	H1804_184_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	184	0	1	09	04	H1804_184_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	184	0	1	09	04	H1804_184_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	185	0	1	09	04	H1804_185_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	185	0	1	09	04	H1804_185_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	185	0	1	09	04	H1804_185_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	185	0	1	09	04	H1804_185_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	185	0	1	09	04	H1804_185_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	185	0	1	09	04	H1804_185_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	185	0	1	09	04	H1804_185_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	185	0	1	09	04	H1804_185_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	187	0	1	09	04	H1804_187_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	187	0	1	09	04	H1804_187_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	187	0	1	09	04	H1804_187_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	187	0	1	09	04	H1804_187_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	187	0	1	09	04	H1804_187_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	187	0	1	09	04	H1804_187_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	187	0	1	09	04	H1804_187_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	187	0	1	09	04	H1804_187_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	188	0	1	09	04	H1804_188_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	188	0	1	09	04	H1804_188_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	188	0	1	09	04	H1804_188_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	188	0	1	09	04	H1804_188_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	188	0	1	09	04	H1804_188_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	188	0	1	09	04	H1804_188_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	188	0	1	09	04	H1804_188_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	188	0	1	09	04	H1804_188_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	190	0	1	09	04	H1804_190_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	190	0	1	09	04	H1804_190_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	190	0	1	09	04	H1804_190_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	190	0	1	09	04	H1804_190_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	190	0	1	09	04	H1804_190_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	190	0	1	09	04	H1804_190_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	190	0	1	09	04	H1804_190_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	190	0	1	09	04	H1804_190_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	192	0	1	09	04	H1804_192_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	192	0	1	09	04	H1804_192_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	192	0	1	09	04	H1804_192_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	192	0	1	09	04	H1804_192_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	192	0	1	09	04	H1804_192_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	192	0	1	09	04	H1804_192_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	192	0	1	09	04	H1804_192_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	192	0	1	09	04	H1804_192_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	193	0	1	09	04	H1804_193_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	193	0	1	09	04	H1804_193_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	193	0	1	09	04	H1804_193_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	193	0	1	09	04	H1804_193_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	193	0	1	09	04	H1804_193_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	193	0	1	09	04	H1804_193_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	193	0	1	09	04	H1804_193_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	193	0	1	09	04	H1804_193_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	195	0	1	09	04	H1804_195_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	195	0	1	09	04	H1804_195_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	195	0	1	09	04	H1804_195_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	195	0	1	09	04	H1804_195_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	195	0	1	09	04	H1804_195_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	195	0	1	09	04	H1804_195_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	195	0	1	09	04	H1804_195_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	195	0	1	09	04	H1804_195_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	196	0	1	09	04	H1804_196_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	196	0	1	09	04	H1804_196_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	196	0	1	09	04	H1804_196_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	196	0	1	09	04	H1804_196_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	196	0	1	09	04	H1804_196_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	196	0	1	09	04	H1804_196_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	196	0	1	09	04	H1804_196_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	196	0	1	09	04	H1804_196_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	197	0	1	09	04	H1804_197_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	197	0	1	09	04	H1804_197_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	197	0	1	09	04	H1804_197_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	197	0	1	09	04	H1804_197_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	197	0	1	09	04	H1804_197_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	197	0	1	09	04	H1804_197_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	197	0	1	09	04	H1804_197_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	197	0	1	09	04	H1804_197_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	198	0	1	09	04	H1804_198_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	198	0	1	09	04	H1804_198_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	198	0	1	09	04	H1804_198_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	198	0	1	09	04	H1804_198_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	198	0	1	09	04	H1804_198_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	198	0	1	09	04	H1804_198_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	198	0	1	09	04	H1804_198_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	198	0	1	09	04	H1804_198_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	199	0	1	09	04	H1804_199_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	199	0	1	09	04	H1804_199_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	199	0	1	09	04	H1804_199_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	199	0	1	09	04	H1804_199_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	199	0	1	09	04	H1804_199_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	199	0	1	09	04	H1804_199_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	199	0	1	09	04	H1804_199_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	199	0	1	09	04	H1804_199_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	200	0	1	09	04	H1804_200_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	200	0	1	09	04	H1804_200_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	200	0	1	09	04	H1804_200_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	200	0	1	09	04	H1804_200_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	200	0	1	09	04	H1804_200_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	200	0	1	09	04	H1804_200_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	200	0	1	09	04	H1804_200_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	200	0	1	09	04	H1804_200_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	201	0	1	09	04	H1804_201_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	201	0	1	09	04	H1804_201_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	201	0	1	09	04	H1804_201_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	201	0	1	09	04	H1804_201_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	201	0	1	09	04	H1804_201_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	201	0	1	09	04	H1804_201_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	201	0	1	09	04	H1804_201_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	201	0	1	09	04	H1804_201_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	202	0	1	09	04	H1804_202_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	202	0	1	09	04	H1804_202_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	202	0	1	09	04	H1804_202_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	202	0	1	09	04	H1804_202_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	202	0	1	09	04	H1804_202_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	202	0	1	09	04	H1804_202_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	202	0	1	09	04	H1804_202_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	202	0	1	09	04	H1804_202_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	203	0	1	09	04	H1804_203_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	203	0	1	09	04	H1804_203_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	203	0	1	09	04	H1804_203_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	203	0	1	09	04	H1804_203_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	203	0	1	09	04	H1804_203_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	203	0	1	09	04	H1804_203_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	203	0	1	09	04	H1804_203_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	203	0	1	09	04	H1804_203_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	204	0	1	09	04	H1804_204_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	204	0	1	09	04	H1804_204_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	204	0	1	09	04	H1804_204_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	204	0	1	09	04	H1804_204_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	204	0	1	09	04	H1804_204_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	204	0	1	09	04	H1804_204_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	204	0	1	09	04	H1804_204_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	204	0	1	09	04	H1804_204_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	205	0	1	09	04	H1804_205_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	205	0	1	09	04	H1804_205_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	205	0	1	09	04	H1804_205_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	205	0	1	09	04	H1804_205_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	205	0	1	09	04	H1804_205_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	205	0	1	09	04	H1804_205_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	205	0	1	09	04	H1804_205_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	205	0	1	09	04	H1804_205_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	207	0	1	09	04	H1804_207_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	207	0	1	09	04	H1804_207_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	207	0	1	09	04	H1804_207_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	207	0	1	09	04	H1804_207_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	207	0	1	09	04	H1804_207_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	207	0	1	09	04	H1804_207_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	207	0	1	09	04	H1804_207_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	207	0	1	09	04	H1804_207_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	209	0	1	09	04	H1804_209_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	209	0	1	09	04	H1804_209_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	209	0	1	09	04	H1804_209_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	209	0	1	09	04	H1804_209_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	209	0	1	09	04	H1804_209_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	209	0	1	09	04	H1804_209_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	209	0	1	09	04	H1804_209_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	209	0	1	09	04	H1804_209_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	210	0	1	09	04	H1804_210_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	210	0	1	09	04	H1804_210_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	210	0	1	09	04	H1804_210_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	210	0	1	09	04	H1804_210_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	210	0	1	09	04	H1804_210_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	210	0	1	09	04	H1804_210_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	210	0	1	09	04	H1804_210_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	210	0	1	09	04	H1804_210_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	211	0	1	09	04	H1804_211_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	211	0	1	09	04	H1804_211_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	211	0	1	09	04	H1804_211_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	211	0	1	09	04	H1804_211_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	211	0	1	09	04	H1804_211_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	211	0	1	09	04	H1804_211_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	211	0	1	09	04	H1804_211_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	211	0	1	09	04	H1804_211_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	212	0	1	09	04	H1804_212_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	212	0	1	09	04	H1804_212_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	212	0	1	09	04	H1804_212_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	212	0	1	09	04	H1804_212_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	212	0	1	09	04	H1804_212_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	212	0	1	09	04	H1804_212_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	212	0	1	09	04	H1804_212_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	212	0	1	09	04	H1804_212_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	213	0	1	09	04	H1804_213_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	213	0	1	09	04	H1804_213_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	213	0	1	09	04	H1804_213_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	213	0	1	09	04	H1804_213_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	213	0	1	09	04	H1804_213_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	213	0	1	09	04	H1804_213_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	213	0	1	09	04	H1804_213_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	213	0	1	09	04	H1804_213_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	214	0	1	09	04	H1804_214_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	214	0	1	09	04	H1804_214_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	214	0	1	09	04	H1804_214_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	214	0	1	09	04	H1804_214_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	214	0	1	09	04	H1804_214_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	214	0	1	09	04	H1804_214_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	214	0	1	09	04	H1804_214_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	214	0	1	09	04	H1804_214_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	216	0	1	09	04	H1804_216_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	216	0	1	09	04	H1804_216_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	216	0	1	09	04	H1804_216_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	216	0	1	09	04	H1804_216_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	216	0	1	09	04	H1804_216_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	216	0	1	09	04	H1804_216_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	216	0	1	09	04	H1804_216_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	216	0	1	09	04	H1804_216_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	217	0	1	09	04	H1804_217_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	217	0	1	09	04	H1804_217_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	217	0	1	09	04	H1804_217_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	217	0	1	09	04	H1804_217_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	217	0	1	09	04	H1804_217_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	217	0	1	09	04	H1804_217_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	217	0	1	09	04	H1804_217_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	217	0	1	09	04	H1804_217_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	218	0	1	09	04	H1804_218_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	218	0	1	09	04	H1804_218_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	218	0	1	09	04	H1804_218_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	218	0	1	09	04	H1804_218_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	218	0	1	09	04	H1804_218_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	218	0	1	09	04	H1804_218_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	218	0	1	09	04	H1804_218_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	218	0	1	09	04	H1804_218_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	219	0	1	09	04	H1804_219_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	219	0	1	09	04	H1804_219_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	219	0	1	09	04	H1804_219_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	219	0	1	09	04	H1804_219_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	219	0	1	09	04	H1804_219_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	219	0	1	09	04	H1804_219_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	219	0	1	09	04	H1804_219_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	219	0	1	09	04	H1804_219_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	223	0	1	09	04	H1804_223_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	223	0	1	09	04	H1804_223_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	223	0	1	09	04	H1804_223_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	223	0	1	09	04	H1804_223_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	223	0	1	09	04	H1804_223_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	223	0	1	09	04	H1804_223_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	223	0	1	09	04	H1804_223_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	223	0	1	09	04	H1804_223_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	224	0	1	09	04	H1804_224_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	224	0	1	09	04	H1804_224_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	224	0	1	09	04	H1804_224_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	224	0	1	09	04	H1804_224_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	224	0	1	09	04	H1804_224_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	224	0	1	09	04	H1804_224_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	224	0	1	09	04	H1804_224_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	224	0	1	09	04	H1804_224_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	225	0	1	09	04	H1804_225_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	225	0	1	09	04	H1804_225_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	225	0	1	09	04	H1804_225_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	225	0	1	09	04	H1804_225_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	225	0	1	09	04	H1804_225_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	225	0	1	09	04	H1804_225_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	225	0	1	09	04	H1804_225_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	225	0	1	09	04	H1804_225_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	226	0	1	09	04	H1804_226_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	226	0	1	09	04	H1804_226_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	226	0	1	09	04	H1804_226_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	226	0	1	09	04	H1804_226_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	226	0	1	09	04	H1804_226_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	226	0	1	09	04	H1804_226_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	226	0	1	09	04	H1804_226_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	226	0	1	09	04	H1804_226_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	227	0	1	09	04	H1804_227_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	227	0	1	09	04	H1804_227_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	227	0	1	09	04	H1804_227_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	227	0	1	09	04	H1804_227_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	227	0	1	09	04	H1804_227_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	227	0	1	09	04	H1804_227_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	227	0	1	09	04	H1804_227_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	227	0	1	09	04	H1804_227_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	228	0	1	09	04	H1804_228_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	228	0	1	09	04	H1804_228_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	228	0	1	09	04	H1804_228_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	228	0	1	09	04	H1804_228_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	228	0	1	09	04	H1804_228_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	228	0	1	09	04	H1804_228_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	228	0	1	09	04	H1804_228_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	228	0	1	09	04	H1804_228_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	229	0	1	09	04	H1804_229_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	229	0	1	09	04	H1804_229_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	229	0	1	09	04	H1804_229_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	229	0	1	09	04	H1804_229_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	229	0	1	09	04	H1804_229_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	229	0	1	09	04	H1804_229_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	229	0	1	09	04	H1804_229_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	229	0	1	09	04	H1804_229_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	230	0	1	09	04	H1804_230_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	230	0	1	09	04	H1804_230_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	230	0	1	09	04	H1804_230_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	230	0	1	09	04	H1804_230_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	230	0	1	09	04	H1804_230_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	230	0	1	09	04	H1804_230_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	230	0	1	09	04	H1804_230_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	230	0	1	09	04	H1804_230_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	231	0	1	09	04	H1804_231_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	231	0	1	09	04	H1804_231_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	231	0	1	09	04	H1804_231_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	231	0	1	09	04	H1804_231_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	231	0	1	09	04	H1804_231_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	231	0	1	09	04	H1804_231_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	231	0	1	09	04	H1804_231_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	231	0	1	09	04	H1804_231_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	232	0	1	09	04	H1804_232_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	232	0	1	09	04	H1804_232_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	232	0	1	09	04	H1804_232_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	232	0	1	09	04	H1804_232_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	232	0	1	09	04	H1804_232_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	232	0	1	09	04	H1804_232_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	232	0	1	09	04	H1804_232_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	232	0	1	09	04	H1804_232_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	233	0	1	09	04	H1804_233_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	233	0	1	09	04	H1804_233_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	233	0	1	09	04	H1804_233_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	233	0	1	09	04	H1804_233_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	233	0	1	09	04	H1804_233_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	233	0	1	09	04	H1804_233_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	233	0	1	09	04	H1804_233_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	233	0	1	09	04	H1804_233_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	234	0	1	09	04	H1804_234_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	234	0	1	09	04	H1804_234_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	234	0	1	09	04	H1804_234_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	234	0	1	09	04	H1804_234_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	234	0	1	09	04	H1804_234_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	234	0	1	09	04	H1804_234_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	234	0	1	09	04	H1804_234_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	234	0	1	09	04	H1804_234_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	235	0	1	09	04	H1804_235_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	235	0	1	09	04	H1804_235_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	235	0	1	09	04	H1804_235_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	235	0	1	09	04	H1804_235_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	235	0	1	09	04	H1804_235_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	235	0	1	09	04	H1804_235_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	235	0	1	09	04	H1804_235_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	235	0	1	09	04	H1804_235_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	236	0	1	09	04	H1804_236_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	236	0	1	09	04	H1804_236_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	236	0	1	09	04	H1804_236_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	236	0	1	09	04	H1804_236_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	236	0	1	09	04	H1804_236_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	236	0	1	09	04	H1804_236_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	236	0	1	09	04	H1804_236_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	236	0	1	09	04	H1804_236_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	237	0	1	09	04	H1804_237_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	237	0	1	09	04	H1804_237_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	237	0	1	09	04	H1804_237_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	237	0	1	09	04	H1804_237_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	237	0	1	09	04	H1804_237_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	237	0	1	09	04	H1804_237_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	237	0	1	09	04	H1804_237_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	237	0	1	09	04	H1804_237_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	238	0	1	09	04	H1804_238_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	238	0	1	09	04	H1804_238_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	238	0	1	09	04	H1804_238_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	238	0	1	09	04	H1804_238_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	238	0	1	09	04	H1804_238_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1804	238	0	1	09	04	H1804_238_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00
H1804	238	0	1	09	04	H1804_238_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	238	0	1	09	04	H1804_238_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	239	0	1	09	04	H1804_239_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	239	0	1	09	04	H1804_239_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	239	0	1	09	04	H1804_239_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	239	0	1	09	04	H1804_239_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	239	0	1	09	04	H1804_239_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	239	0	1	09	04	H1804_239_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	239	0	1	09	04	H1804_239_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	239	0	1	09	04	H1804_239_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	240	0	1	09	04	H1804_240_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	240	0	1	09	04	H1804_240_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	240	0	1	09	04	H1804_240_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	240	0	1	09	04	H1804_240_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	240	0	1	09	04	H1804_240_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	240	0	1	09	04	H1804_240_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	240	0	1	09	04	H1804_240_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	240	0	1	09	04	H1804_240_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	241	0	1	09	04	H1804_241_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	241	0	1	09	04	H1804_241_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	241	0	1	09	04	H1804_241_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	241	0	1	09	04	H1804_241_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	241	0	1	09	04	H1804_241_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	241	0	1	09	04	H1804_241_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	241	0	1	09	04	H1804_241_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	241	0	1	09	04	H1804_241_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	245	0	1	09	04	H1804_245_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	245	0	1	09	04	H1804_245_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	245	0	1	09	04	H1804_245_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	245	0	1	09	04	H1804_245_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	245	0	1	09	04	H1804_245_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	245	0	1	09	04	H1804_245_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	245	0	1	09	04	H1804_245_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	245	0	1	09	04	H1804_245_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	246	0	1	09	04	H1804_246_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	246	0	1	09	04	H1804_246_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	246	0	1	09	04	H1804_246_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	246	0	1	09	04	H1804_246_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	246	0	1	09	04	H1804_246_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	246	0	1	09	04	H1804_246_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	246	0	1	09	04	H1804_246_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	246	0	1	09	04	H1804_246_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	251	0	1	09	04	H1804_251_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	251	0	1	09	04	H1804_251_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	251	0	1	09	04	H1804_251_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	251	0	1	09	04	H1804_251_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	251	0	1	09	04	H1804_251_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	251	0	1	09	04	H1804_251_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	251	0	1	09	04	H1804_251_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	251	0	1	09	04	H1804_251_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	252	0	1	09	04	H1804_252_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	252	0	1	09	04	H1804_252_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	252	0	1	09	04	H1804_252_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	252	0	1	09	04	H1804_252_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	252	0	1	09	04	H1804_252_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	252	0	1	09	04	H1804_252_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	252	0	1	09	04	H1804_252_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	252	0	1	09	04	H1804_252_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	254	0	1	09	04	H1804_254_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	254	0	1	09	04	H1804_254_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	254	0	1	09	04	H1804_254_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	254	0	1	09	04	H1804_254_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	254	0	1	09	04	H1804_254_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	254	0	1	09	04	H1804_254_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	254	0	1	09	04	H1804_254_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	254	0	1	09	04	H1804_254_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	257	0	1	09	04	H1804_257_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	257	0	1	09	04	H1804_257_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	257	0	1	09	04	H1804_257_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	257	0	1	09	04	H1804_257_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	257	0	1	09	04	H1804_257_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	257	0	1	09	04	H1804_257_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	257	0	1	09	04	H1804_257_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	257	0	1	09	04	H1804_257_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	258	0	1	09	04	H1804_258_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	258	0	1	09	04	H1804_258_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	258	0	1	09	04	H1804_258_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	258	0	1	09	04	H1804_258_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	258	0	1	09	04	H1804_258_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	258	0	1	09	04	H1804_258_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	258	0	1	09	04	H1804_258_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	258	0	1	09	04	H1804_258_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	261	0	1	09	04	H1804_261_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	261	0	1	09	04	H1804_261_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	261	0	1	09	04	H1804_261_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	261	0	1	09	04	H1804_261_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	261	0	1	09	04	H1804_261_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	261	0	1	09	04	H1804_261_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	261	0	1	09	04	H1804_261_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	261	0	1	09	04	H1804_261_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	263	0	1	09	04	H1804_263_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	263	0	1	09	04	H1804_263_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	263	0	1	09	04	H1804_263_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	263	0	1	09	04	H1804_263_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	263	0	1	09	04	H1804_263_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	263	0	1	09	04	H1804_263_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	263	0	1	09	04	H1804_263_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	263	0	1	09	04	H1804_263_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	269	0	1	09	04	H1804_269_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	269	0	1	09	04	H1804_269_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	269	0	1	09	04	H1804_269_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	269	0	1	09	04	H1804_269_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	269	0	1	09	04	H1804_269_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	269	0	1	09	04	H1804_269_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	269	0	1	09	04	H1804_269_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	269	0	1	09	04	H1804_269_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	270	0	1	09	04	H1804_270_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	270	0	1	09	04	H1804_270_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	270	0	1	09	04	H1804_270_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	270	0	1	09	04	H1804_270_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	270	0	1	09	04	H1804_270_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	270	0	1	09	04	H1804_270_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	270	0	1	09	04	H1804_270_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	270	0	1	09	04	H1804_270_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	272	0	1	09	04	H1804_272_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	272	0	1	09	04	H1804_272_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	272	0	1	09	04	H1804_272_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	272	0	1	09	04	H1804_272_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	272	0	1	09	04	H1804_272_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	272	0	1	09	04	H1804_272_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	272	0	1	09	04	H1804_272_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	272	0	1	09	04	H1804_272_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	273	0	1	09	04	H1804_273_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	273	0	1	09	04	H1804_273_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	273	0	1	09	04	H1804_273_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	273	0	1	09	04	H1804_273_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	273	0	1	09	04	H1804_273_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	273	0	1	09	04	H1804_273_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	273	0	1	09	04	H1804_273_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	273	0	1	09	04	H1804_273_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	274	0	1	09	04	H1804_274_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	274	0	1	09	04	H1804_274_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	274	0	1	09	04	H1804_274_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	274	0	1	09	04	H1804_274_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	274	0	1	09	04	H1804_274_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	274	0	1	09	04	H1804_274_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1804	274	0	1	09	04	H1804_274_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1804	274	0	1	09	04	H1804_274_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	275	0	1	09	04	H1804_275_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	275	0	1	09	04	H1804_275_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	275	0	1	09	04	H1804_275_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	275	0	1	09	04	H1804_275_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	275	0	1	09	04	H1804_275_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	275	0	1	09	04	H1804_275_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	275	0	1	09	04	H1804_275_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	275	0	1	09	04	H1804_275_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	278	0	1	09	04	H1804_278_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	278	0	1	09	04	H1804_278_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	278	0	1	09	04	H1804_278_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	278	0	1	09	04	H1804_278_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	278	0	1	09	04	H1804_278_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	278	0	1	09	04	H1804_278_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	278	0	1	09	04	H1804_278_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	278	0	1	09	04	H1804_278_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	279	0	1	09	04	H1804_279_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	279	0	1	09	04	H1804_279_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	279	0	1	09	04	H1804_279_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	279	0	1	09	04	H1804_279_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	279	0	1	09	04	H1804_279_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	279	0	1	09	04	H1804_279_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	279	0	1	09	04	H1804_279_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	279	0	1	09	04	H1804_279_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	280	0	1	09	04	H1804_280_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	280	0	1	09	04	H1804_280_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	280	0	1	09	04	H1804_280_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	280	0	1	09	04	H1804_280_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	280	0	1	09	04	H1804_280_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	280	0	1	09	04	H1804_280_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	280	0	1	09	04	H1804_280_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	280	0	1	09	04	H1804_280_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	281	0	1	09	04	H1804_281_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	281	0	1	09	04	H1804_281_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	281	0	1	09	04	H1804_281_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	281	0	1	09	04	H1804_281_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	281	0	1	09	04	H1804_281_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	281	0	1	09	04	H1804_281_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	281	0	1	09	04	H1804_281_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	281	0	1	09	04	H1804_281_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	284	0	1	09	04	H1804_284_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	284	0	1	09	04	H1804_284_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	284	0	1	09	04	H1804_284_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	284	0	1	09	04	H1804_284_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	284	0	1	09	04	H1804_284_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	284	0	1	09	04	H1804_284_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	284	0	1	09	04	H1804_284_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	284	0	1	09	04	H1804_284_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	285	0	1	09	04	H1804_285_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	285	0	1	09	04	H1804_285_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	285	0	1	09	04	H1804_285_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	285	0	1	09	04	H1804_285_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	285	0	1	09	04	H1804_285_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	285	0	1	09	04	H1804_285_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	285	0	1	09	04	H1804_285_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	285	0	1	09	04	H1804_285_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	286	0	1	09	04	H1804_286_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	286	0	1	09	04	H1804_286_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	286	0	1	09	04	H1804_286_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	286	0	1	09	04	H1804_286_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	286	0	1	09	04	H1804_286_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	286	0	1	09	04	H1804_286_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	286	0	1	09	04	H1804_286_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	286	0	1	09	04	H1804_286_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	287	0	1	09	04	H1804_287_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	287	0	1	09	04	H1804_287_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	287	0	1	09	04	H1804_287_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	287	0	1	09	04	H1804_287_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	287	0	1	09	04	H1804_287_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	287	0	1	09	04	H1804_287_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	287	0	1	09	04	H1804_287_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	287	0	1	09	04	H1804_287_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	288	0	1	09	04	H1804_288_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	288	0	1	09	04	H1804_288_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	288	0	1	09	04	H1804_288_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	288	0	1	09	04	H1804_288_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	288	0	1	09	04	H1804_288_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	288	0	1	09	04	H1804_288_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	288	0	1	09	04	H1804_288_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	288	0	1	09	04	H1804_288_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1804	289	0	1	09	04	H1804_289_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	289	0	1	09	04	H1804_289_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1804	289	0	1	09	04	H1804_289_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	289	0	1	09	04	H1804_289_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1804	289	0	1	09	04	H1804_289_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	289	0	1	09	04	H1804_289_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1804	289	0	1	09	04	H1804_289_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1804	289	0	1	09	04	H1804_289_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1806	001	0	1	04	01	H1806_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1806	001	0	1	04	01	H1806_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1806	001	0	1	04	01	H1806_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1806	001	0	1	04	01	H1806_001_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1806	001	0	1	04	01	H1806_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1806	001	0	1	04	01	H1806_001_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1806	001	0	1	04	01	H1806_001_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1806	001	0	1	04	01	H1806_001_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1806	002	0	1	04	01	H1806_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1806	002	0	1	04	01	H1806_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1806	002	0	1	04	01	H1806_002_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1806	002	0	1	04	01	H1806_002_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1806	002	0	1	04	01	H1806_002_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1806	002	0	1	04	01	H1806_002_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1806	002	0	1	04	01	H1806_002_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H1806	002	0	1	04	01	H1806_002_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1837	001	0	1	01	01	H1837_001_0	10	4	4	1	Tier 4 specialty	100011	1	1				Tier 4 specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 specialty	2	1	Tier 4 specialty	20	20								20		20	20								20	Tier 4 specialty																					
H1837	001	0	1	01	01	H1837_001_0	10	3	4	1	Tier 3 non-preferred brand	100000	1	2				Tier 3 non-preferred brand	111000000010110000000	31	93								31		31								93	34	Tier 3 non-preferred brand	2	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	177.00								59.00		59.00	118.00								59.00
H1837	001	0	1	01	01	H1837_001_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H1837	001	0	1	01	01	H1837_001_0	10	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H1837	002	0	1	01	01	H1837_002_0	8	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H1837	002	0	1	01	01	H1837_002_0	8	4	4	1	Tier 4 specialty	100011	1	1				Tier 4 specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 specialty	2	1	Tier 4 specialty	20	20								20		20	20								20	Tier 4 specialty																					
H1837	002	0	1	01	01	H1837_002_0	8	3	4	1	Tier 3 non-preferred brand	100000	1	2				Tier 3 non-preferred brand	111000000010110000000	31	93								31		31								93	34	Tier 3 non-preferred brand	2	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	177.00								59.00		59.00	118.00								59.00
H1837	002	0	1	01	01	H1837_002_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H1837	003	0	1	01	01	H1837_003_0	5	1	4	3	Tier 1 Generic	010000	1	2	1		1	Tier 1 Generic	111000000010110000000	31	93								31		31								93	31	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H1837	003	0	1	01	01	H1837_003_0	5	4	4	1	Tier 4 Specialty	100011	1	1				Tier 4 Specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 Specialty	2	1	Tier 4 Specialty	20	20								20		20	20								20	Tier 4 Specialty																					
H1837	003	0	1	01	01	H1837_003_0	5	3	4	1	Tier 3 Non-Preferred Brand	100000	1	2				Tier 3 Non-Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	59.00	177.00								59.00		59.00	118.00								59.00
H1837	003	0	1	01	01	H1837_003_0	5	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H1837	003	0	1	01	01	H1837_003_0	5	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H1837	003	0	1	01	01	H1837_003_0	5	3	4	3	Tier 3 Non-Preferred Brand	100000	1	2	2			Tier 3 Non-Preferred Brand																							Tier 3 Non-Preferred Brand			Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand																					
H1837	003	0	1	01	01	H1837_003_0	5	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1837	003	0	1	01	01	H1837_003_0	5	4	4	3	Tier 4 Specialty	100011	1	1	2			Tier 4 Specialty																							Tier 4 Specialty			Tier 4 Specialty																						Tier 4 Specialty																					
H1837	004	0	1	01	01	H1837_004_0	7	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H1837	004	0	1	01	01	H1837_004_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H1837	004	0	1	01	01	H1837_004_0	7	3	4	1	Tier 3 non-preferred brand	100000	1	2				Tier 3 non-preferred brand	111000000010110000000	31	93								31		31								93	34	Tier 3 non-preferred brand	2	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	177.00								59.00		59.00	118.00								59.00
H1837	004	0	1	01	01	H1837_004_0	7	4	4	1	Tier 4 specialty	100011	1	1				Tier 4 specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 specialty	2	1	Tier 4 specialty	20	20								20		20	20								20	Tier 4 specialty																					
H1846	001	0	1	04	01	H1846_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H1846	001	0	1	04	01	H1846_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00
H1846	001	0	1	04	01	H1846_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H1846	001	0	1	04	01	H1846_001_0	6	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H1846	001	0	1	04	01	H1846_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H1846	001	0	1	04	01	H1846_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H1846	001	0	1	04	01	H1846_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1846	001	0	1	04	01	H1846_001_0	6	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H1849	005	0	1	01	01	H1849_005_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1849	005	0	1	01	01	H1849_005_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H1849	005	0	1	01	01	H1849_005_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1849	005	0	1	01	01	H1849_005_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1849	005	0	1	01	01	H1849_005_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1849	005	0	1	01	01	H1849_005_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1849	005	0	1	01	01	H1849_005_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H1849	005	0	1	01	01	H1849_005_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1849	005	0	1	01	01	H1849_005_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1849	005	0	1	01	01	H1849_005_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1849	014	0	1	01	01	H1849_014_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H1849	014	0	1	01	01	H1849_014_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H1849	014	0	1	01	01	H1849_014_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H1849	014	0	1	01	01	H1849_014_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1849	014	0	1	01	01	H1849_014_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H1849	014	0	1	01	01	H1849_014_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H1849	014	0	1	01	01	H1849_014_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H1849	014	0	1	01	01	H1849_014_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H1849	014	0	1	01	01	H1849_014_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H1849	014	0	1	01	01	H1849_014_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H1903	011	0	1	01	01	H1903_011_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1903	011	0	1	01	01	H1903_011_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00								83.00			249.00								83.00
H1903	011	0	1	01	01	H1903_011_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00
H1903	011	0	1	01	01	H1903_011_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	014	0	1	02	01	H1903_014_0	9	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	014	0	1	02	01	H1903_014_0	9	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H1903	014	0	1	02	01	H1903_014_0	9	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00								86.00			258.00								86.00
H1903	014	0	1	02	01	H1903_014_0	9	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1903	018	0	1	02	01	H1903_018_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	018	0	1	02	01	H1903_018_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1903	018	0	1	02	01	H1903_018_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00			120.00								40.00
H1903	018	0	1	02	01	H1903_018_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00
H1903	018	0	1	02	01	H1903_018_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	018	0	1	02	01	H1903_018_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1903	018	0	1	02	01	H1903_018_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1903	018	0	1	02	01	H1903_018_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1903	022	0	1	02	01	H1903_022_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	022	0	1	02	01	H1903_022_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H1903	022	0	1	02	01	H1903_022_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H1903	022	0	1	02	01	H1903_022_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H1903	022	0	1	02	01	H1903_022_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	022	0	1	02	01	H1903_022_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H1903	022	0	1	02	01	H1903_022_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H1903	022	0	1	02	01	H1903_022_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H1903	023	0	1	01	01	H1903_023_0	8	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H1903	023	0	1	01	01	H1903_023_0	8	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H1903	023	0	1	01	01	H1903_023_0	8	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00								86.00			258.00								86.00
H1903	023	0	1	01	01	H1903_023_0	8	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H1906	001	0	1	09	04	H1906_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1906	001	0	1	09	04	H1906_001_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	001	0	1	09	04	H1906_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1906	001	0	1	09	04	H1906_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1906	001	0	1	09	04	H1906_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1906	001	0	1	09	04	H1906_001_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	001	0	1	09	04	H1906_001_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1906	001	0	1	09	04	H1906_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1906	002	0	1	09	04	H1906_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1906	002	0	1	09	04	H1906_002_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1906	002	0	1	09	04	H1906_002_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1906	002	0	1	09	04	H1906_002_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	002	0	1	09	04	H1906_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1906	002	0	1	09	04	H1906_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H1906	002	0	1	09	04	H1906_002_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1906	002	0	1	09	04	H1906_002_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	003	0	1	09	04	H1906_003_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	003	0	1	09	04	H1906_003_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	003	0	1	09	04	H1906_003_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	003	0	1	09	04	H1906_003_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	003	0	1	09	04	H1906_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	003	0	1	09	04	H1906_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	003	0	1	09	04	H1906_003_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	003	0	1	09	04	H1906_003_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	006	0	1	09	04	H1906_006_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	006	0	1	09	04	H1906_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	006	0	1	09	04	H1906_006_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	006	0	1	09	04	H1906_006_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	006	0	1	09	04	H1906_006_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	006	0	1	09	04	H1906_006_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	006	0	1	09	04	H1906_006_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	006	0	1	09	04	H1906_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	007	0	1	09	04	H1906_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	007	0	1	09	04	H1906_007_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	007	0	1	09	04	H1906_007_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	007	0	1	09	04	H1906_007_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00
H1906	007	0	1	09	04	H1906_007_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1906	007	0	1	09	04	H1906_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H1906	007	0	1	09	04	H1906_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00
H1906	007	0	1	09	04	H1906_007_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1944	001	0	1	02	01	H1944_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H1944	001	0	1	02	01	H1944_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H1944	001	0	1	02	01	H1944_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H1944	001	0	1	02	01	H1944_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H1951	001	0	1	01	01	H1951_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00
H1951	001	0	1	01	01	H1951_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H1951	001	0	1	01	01	H1951_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	001	0	1	01	01	H1951_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1951	001	0	1	01	01	H1951_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H1951	001	0	1	01	01	H1951_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00
H1951	001	0	1	01	01	H1951_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	001	0	1	01	01	H1951_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H1951	005	0	1	01	01	H1951_005_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00
H1951	005	0	1	01	01	H1951_005_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1951	005	0	1	01	01	H1951_005_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1951	005	0	1	01	01	H1951_005_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1951	005	0	1	01	01	H1951_005_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1951	005	0	1	01	01	H1951_005_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1951	005	0	1	01	01	H1951_005_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00
H1951	005	0	1	01	01	H1951_005_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1951	013	0	1	01	01	H1951_013_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1951	013	0	1	01	01	H1951_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H1951	013	0	1	01	01	H1951_013_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1951	013	0	1	01	01	H1951_013_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	013	0	1	01	01	H1951_013_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H1951	013	0	1	01	01	H1951_013_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	013	0	1	01	01	H1951_013_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H1951	013	0	1	01	01	H1951_013_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1951	017	0	1	01	01	H1951_017_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H1951	017	0	1	01	01	H1951_017_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1951	017	0	1	01	01	H1951_017_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1951	017	0	1	01	01	H1951_017_0	8	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H1951	019	0	1	01	01	H1951_019_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1951	019	0	1	01	01	H1951_019_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H1951	019	0	1	01	01	H1951_019_0	9	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	019	0	1	01	01	H1951_019_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1951	021	0	1	01	01	H1951_021_0	8	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	021	0	1	01	01	H1951_021_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H1951	021	0	1	01	01	H1951_021_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1951	021	0	1	01	01	H1951_021_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H1951	023	0	1	01	01	H1951_023_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1951	023	0	1	01	01	H1951_023_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	023	0	1	01	01	H1951_023_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1951	023	0	1	01	01	H1951_023_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H1951	023	0	1	01	01	H1951_023_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H1951	023	0	1	01	01	H1951_023_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1951	023	0	1	01	01	H1951_023_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H1951	023	0	1	01	01	H1951_023_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H1961	001	0	1	01	01	H1961_001_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	100.00		50.00	150.00		50.00			100.00								50.00
H1961	001	0	1	01	01	H1961_001_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H1961	001	0	1	01	01	H1961_001_0	9	1	4	3	Generic	011100	3	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H1961	001	0	1	01	01	H1961_001_0	9	2	4	3	Preferred Brand	000001	3	2	1		1	Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H1961	001	0	1	01	01	H1961_001_0	9	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1961	001	0	1	01	01	H1961_001_0	9	4	4	3	Specialty	110010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1961	001	0	1	01	01	H1961_001_0	9	4	4	1	Specialty	110010	1	1				Specialty	100011011010010000000				30	90		30	90		30										90	31	Specialty	2	1	Specialty				20	20		20	20		20			20								20	Specialty																					
H1961	001	0	1	01	01	H1961_001_0	9	1	4	1	Generic	011100	3	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H1961	002	0	1	02	01	H1961_002_0	12	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	100.00		50.00	150.00		50.00			100.00								50.00
H1961	002	0	1	02	01	H1961_002_0	12	4	4	1	Specialty	110010	1	1				Specialty	100011011010010000000				30	90		30	90		30										90	31	Specialty	2	1	Specialty				20	20		20	20		20			20								20	Specialty																					
H1961	002	0	1	02	01	H1961_002_0	12	1	4	3	Generic	011100	3	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H1961	002	0	1	02	01	H1961_002_0	12	2	4	3	Preferred Brand	000001	3	2	1		1	Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H1961	002	0	1	02	01	H1961_002_0	12	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H1961	002	0	1	02	01	H1961_002_0	12	4	4	3	Specialty	110010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H1961	002	0	1	02	01	H1961_002_0	12	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H1961	002	0	1	02	01	H1961_002_0	12	1	4	1	Generic	011100	3	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H2001	001	0	1	04	01	H2001_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H2001	001	0	1	04	01	H2001_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H2001	001	0	1	04	01	H2001_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2001	001	0	1	04	01	H2001_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2001	003	0	1	04	01	H2001_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H2001	003	0	1	04	01	H2001_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H2001	003	0	1	04	01	H2001_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2001	003	0	1	04	01	H2001_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2003	001	0	1	04	01	H2003_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2003	001	0	1	04	01	H2003_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2003	001	0	1	04	01	H2003_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2003	001	0	1	04	01	H2003_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2003	002	0	1	04	01	H2003_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2003	002	0	1	04	01	H2003_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2003	002	0	1	04	01	H2003_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2003	002	0	1	04	01	H2003_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2029	001	0	1	04	01	H2029_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2029	001	0	1	04	01	H2029_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2029	001	0	1	04	01	H2029_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00
H2029	001	0	1	04	01	H2029_001_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2029	001	0	1	04	01	H2029_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2029	001	0	1	04	01	H2029_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2029	001	0	1	04	01	H2029_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00
H2029	001	0	1	04	01	H2029_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2047	001	0	1	04	01	H2047_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H2047	001	0	1	04	01	H2047_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H2047	001	0	1	04	01	H2047_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H2047	001	0	1	04	01	H2047_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H2047	001	0	1	04	01	H2047_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H2047	002	0	1	04	01	H2047_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H2047	002	0	1	04	01	H2047_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H2047	002	0	1	04	01	H2047_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H2047	002	0	1	04	01	H2047_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H2047	002	0	1	04	01	H2047_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H2047	002	0	1	04	01	H2047_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H2047	002	0	1	04	01	H2047_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H2047	002	0	1	04	01	H2047_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H2047	002	0	1	04	01	H2047_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H2047	002	0	1	04	01	H2047_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H2108	022	0	1	01	01	H2108_022_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H2108	022	0	1	01	01	H2108_022_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H2108	022	0	1	01	01	H2108_022_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H2108	022	0	1	01	01	H2108_022_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2108	023	0	1	02	01	H2108_023_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H2108	023	0	1	02	01	H2108_023_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H2108	023	0	1	02	01	H2108_023_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H2108	023	0	1	02	01	H2108_023_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2108	026	0	1	02	01	H2108_026_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H2108	026	0	1	02	01	H2108_026_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H2108	026	0	1	02	01	H2108_026_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H2108	026	0	1	02	01	H2108_026_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2108	028	0	1	01	01	H2108_028_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H2108	028	0	1	01	01	H2108_028_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H2108	028	0	1	01	01	H2108_028_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H2108	028	0	1	01	01	H2108_028_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2111	001	0	1	04	01	H2111_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2111	001	0	1	04	01	H2111_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2111	001	0	1	04	01	H2111_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2111	001	0	1	04	01	H2111_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2111	011	0	1	04	01	H2111_011_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2111	011	0	1	04	01	H2111_011_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2111	011	0	1	04	01	H2111_011_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2111	011	0	1	04	01	H2111_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2111	012	0	1	04	01	H2111_012_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2111	012	0	1	04	01	H2111_012_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2111	012	0	1	04	01	H2111_012_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2111	012	0	1	04	01	H2111_012_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2111	013	0	1	04	01	H2111_013_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2111	013	0	1	04	01	H2111_013_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2111	013	0	1	04	01	H2111_013_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2111	013	0	1	04	01	H2111_013_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2112	002	0	1	01	01	H2112_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H2112	002	0	1	01	01	H2112_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H2112	002	0	1	01	01	H2112_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H2112	002	0	1	01	01	H2112_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H2112	002	0	1	01	01	H2112_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H2112	002	0	1	01	01	H2112_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H2112	002	0	1	01	01	H2112_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H2112	002	0	1	01	01	H2112_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H2112	002	0	1	01	01	H2112_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H2112	002	0	1	01	01	H2112_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H2112	007	0	1	01	01	H2112_007_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H2112	007	0	1	01	01	H2112_007_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H2112	007	0	1	01	01	H2112_007_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H2112	007	0	1	01	01	H2112_007_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H2112	007	0	1	01	01	H2112_007_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H2112	009	0	1	01	01	H2112_009_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H2112	009	0	1	01	01	H2112_009_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H2112	009	0	1	01	01	H2112_009_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H2112	009	0	1	01	01	H2112_009_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H2112	009	0	1	01	01	H2112_009_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H2112	009	0	1	01	01	H2112_009_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H2112	009	0	1	01	01	H2112_009_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H2112	009	0	1	01	01	H2112_009_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H2112	009	0	1	01	01	H2112_009_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H2112	009	0	1	01	01	H2112_009_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H2112	011	0	1	01	01	H2112_011_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H2112	011	0	1	01	01	H2112_011_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H2112	011	0	1	01	01	H2112_011_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H2112	011	0	1	01	01	H2112_011_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H2112	011	0	1	01	01	H2112_011_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H2112	013	0	1	01	01	H2112_013_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H2112	013	0	1	01	01	H2112_013_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H2112	013	0	1	01	01	H2112_013_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					58.00			87.00		29.00
H2112	013	0	1	01	01	H2112_013_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H2112	013	0	1	01	01	H2112_013_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H2112	014	0	1	01	01	H2112_014_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H2112	014	0	1	01	01	H2112_014_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H2112	014	0	1	01	01	H2112_014_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H2112	014	0	1	01	01	H2112_014_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H2112	014	0	1	01	01	H2112_014_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H2112	015	0	1	01	01	H2112_015_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H2112	015	0	1	01	01	H2112_015_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H2112	015	0	1	01	01	H2112_015_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H2112	015	0	1	01	01	H2112_015_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H2112	015	0	1	01	01	H2112_015_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H2150	002	0	1	18	06	H2150_002_0	7	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	002	0	1	18	06	H2150_002_0	7	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Brand	2	2	Brand																						Brand				30.00	90.00		55.00	165.00		55.00					25.00	75.00		55.00	165.00		55.00
H2150	002	0	1	18	06	H2150_002_0	7	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2150	002	0	1	18	06	H2150_002_0	7	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H2150	002	0	1	18	06	H2150_002_0	7	3	4	1	Specialty	000010	1	1				Specialty	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Specialty	2	1	Specialty				10	10		15	15		15					10	10		15	15		15	Specialty																					
H2150	002	0	1	18	06	H2150_002_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	009	0	1	18	06	H2150_009_0	8	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Brand	2	2	Brand																						Brand				35.00	105.00		60.00	180.00		60.00					30.00	90.00		60.00	180.00		60.00
H2150	009	0	1	18	06	H2150_009_0	8	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	009	0	1	18	06	H2150_009_0	8	3	4	1	Specialty	000010	1	1				Specialty	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Specialty	2	1	Specialty				25	25		25	25		25					25	25		25	25		25	Specialty																					
H2150	028	0	2	18	06	H2150_028_0	11	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Brand	2	2	Brand																						Brand				30.00	90.00		55.00	165.00		55.00					25.00	75.00		55.00	165.00		55.00
H2150	028	0	2	18	06	H2150_028_0	11	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	028	0	2	18	06	H2150_028_0	11	3	4	1	Specialty	000010	1	1				Specialty	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Specialty	2	1	Specialty				10	10		15	15		15					10	10		15	15		15	Specialty																					
H2150	028	0	2	18	06	H2150_028_0	11	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2150	028	0	2	18	06	H2150_028_0	11	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H2150	028	0	2	18	06	H2150_028_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	029	0	2	18	06	H2150_029_0	11	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Generic	2	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00
H2150	029	0	2	18	06	H2150_029_0	11	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Brand	2	2	Brand																						Brand				35.00	105.00		60.00	180.00		60.00					30.00	90.00		60.00	180.00		60.00
H2150	029	0	2	18	06	H2150_029_0	11	3	4	1	Specialty	000010	1	1				Specialty	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Specialty	2	1	Specialty				25	25		25	25		25					25	25		25	25		25	Specialty																					
H2169	002	0	1	01	01	H2169_002_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00
H2169	002	0	1	01	01	H2169_002_0	4	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H2169	002	0	1	01	01	H2169_002_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
H2169	002	0	1	01	01	H2169_002_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H2169	003	0	1	01	01	H2169_003_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H2169	003	0	1	01	01	H2169_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H2169	003	0	1	01	01	H2169_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H2169	003	0	1	01	01	H2169_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H2169	005	0	1	01	01	H2169_005_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H2169	005	0	1	01	01	H2169_005_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00
H2169	005	0	1	01	01	H2169_005_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
H2169	005	0	1	01	01	H2169_005_0	4	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H2169	006	0	1	01	01	H2169_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H2169	006	0	1	01	01	H2169_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H2169	006	0	1	01	01	H2169_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H2169	006	0	1	01	01	H2169_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H2174	002	0	1	01	01	H2174_002_0	6	3	4	3	Non-Preferred Medication	100100	1	2	2			Non-Preferred Medication																							Non-Preferred Medication			Non-Preferred Medication																						Non-Preferred Medication																					
H2174	002	0	1	01	01	H2174_002_0	6	2	4	3	Preferred Brand	000011	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2174	002	0	1	01	01	H2174_002_0	6	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H2174	002	0	1	01	01	H2174_002_0	6	3	4	1	Non-Preferred Medication	100100	1	2				Non-Preferred Medication	111000000010010000000	30	90								30										90	31	Non-Preferred Medication	2	2	Non-Preferred Medication																						Non-Preferred Medication	35.00	70.00								35.00			70.00								35.00
H2174	002	0	1	01	01	H2174_002_0	6	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H2174	002	0	1	01	01	H2174_002_0	6	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00
H2182	001	0	1	02	01	H2182_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2182	001	0	1	02	01	H2182_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H2182	001	0	1	02	01	H2182_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H2182	001	0	1	02	01	H2182_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00						4.00			6.00		2.00
H2228	001	0	1	04	01	H2228_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2228	001	0	1	04	01	H2228_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2228	001	0	1	04	01	H2228_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2228	001	0	1	04	01	H2228_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2228	002	0	1	04	01	H2228_002_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2228	002	0	1	04	01	H2228_002_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2228	002	0	1	04	01	H2228_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2228	002	0	1	04	01	H2228_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2228	009	0	1	04	01	H2228_009_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2228	009	0	1	04	01	H2228_009_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2228	009	0	1	04	01	H2228_009_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2228	009	0	1	04	01	H2228_009_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2229	028	0	1	04	01	H2229_028_0	6	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2229	028	0	1	04	01	H2229_028_0	6	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2229	028	0	1	04	01	H2229_028_0	6	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2229	028	0	1	04	01	H2229_028_0	6	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2229	028	0	1	04	01	H2229_028_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2229	028	0	1	04	01	H2229_028_0	6	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2229	029	0	1	04	01	H2229_029_0	6	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2229	029	0	1	04	01	H2229_029_0	6	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2229	029	0	1	04	01	H2229_029_0	6	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2230	002	0	1	04	01	H2230_002_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H2230	002	0	1	04	01	H2230_002_0	8	4	4	1	Speciality Medications	110001	1	1				Speciality Medications	111000000010110000000	30	90								30		30								90	31	Speciality Medications	2	1	Speciality Medications	25	25								25		25	25								25	Speciality Medications																					
H2230	002	0	1	04	01	H2230_002_0	8	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2230	002	0	1	04	01	H2230_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H2230	006	0	1	04	01	H2230_006_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2230	006	0	1	04	01	H2230_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	56.00								28.00
H2230	006	0	1	04	01	H2230_006_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00								58.00		58.00	116.00								58.00
H2230	006	0	1	04	01	H2230_006_0	7	4	4	1	Specialty Medication	110001	1	1				Specialty Medication	111000000010110000000	30	90								30		30								90	31	Specialty Medication	2	1	Specialty Medication	33	33								33		33	33								33	Specialty Medication																					
H2230	006	0	1	04	01	H2230_006_0	7	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2230	006	0	1	04	01	H2230_006_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2230	006	0	1	04	01	H2230_006_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2230	006	0	1	04	01	H2230_006_0	7	4	4	3	Specialty Medication	110001	1	1	2			Specialty Medication																							Specialty Medication			Specialty Medication																						Specialty Medication																					
H2237	001	0	1	01	01	H2237_001_0	5	2	4	1	Other	010010	1	2				Other	110000000010000000000	30									30											31	Other	2	2	Other																						Other	45.00									45.00											45.00
H2237	001	0	1	01	01	H2237_001_0	5	1	4	1	Generic	010000	1	2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H2237	002	0	1	01	01	H2237_002_0	5	2	4	1	Other	010010	1	2				Other	110000000010000000000	30									30											31	Other	2	2	Other																						Other	45.00									45.00											45.00
H2237	002	0	1	01	01	H2237_002_0	5	1	4	1	Generic	010000	1	2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H2237	006	0	1	01	01	H2237_006_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	1.00	3.00								1.00			3.00								1.00
H2237	006	0	1	01	01	H2237_006_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	37.00	74.00								37.00			74.00								37.00
H2237	006	0	1	01	01	H2237_006_0	5	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2256	001	1	1	01	01	H2256_001_1	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2256	001	1	1	01	01	H2256_001_1	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	001	1	1	01	01	H2256_001_1	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2256	001	1	1	01	01	H2256_001_1	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	001	1	1	01	01	H2256_001_1	8	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2256	001	1	1	01	01	H2256_001_1	8	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2256	001	2	1	01	01	H2256_001_2	9	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2256	001	2	1	01	01	H2256_001_2	9	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	001	2	1	01	01	H2256_001_2	9	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2256	001	2	1	01	01	H2256_001_2	9	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2256	001	2	1	01	01	H2256_001_2	9	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2256	001	2	1	01	01	H2256_001_2	9	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	015	1	1	01	01	H2256_015_1	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	015	1	1	01	01	H2256_015_1	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2256	015	1	1	01	01	H2256_015_1	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2256	015	2	1	01	01	H2256_015_2	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2256	015	2	1	01	01	H2256_015_2	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	015	2	1	01	01	H2256_015_2	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2256	017	1	1	01	01	H2256_017_1	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	017	1	1	01	01	H2256_017_1	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2256	017	1	1	01	01	H2256_017_1	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2256	017	1	1	01	01	H2256_017_1	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	017	1	1	01	01	H2256_017_1	8	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2256	017	1	1	01	01	H2256_017_1	8	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2256	017	7	1	01	01	H2256_017_7	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	017	7	1	01	01	H2256_017_7	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2256	017	7	1	01	01	H2256_017_7	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2256	017	7	1	01	01	H2256_017_7	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	017	7	1	01	01	H2256_017_7	8	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2256	017	7	1	01	01	H2256_017_7	8	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2256	018	1	1	01	01	H2256_018_1	8	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	018	1	1	01	01	H2256_018_1	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2256	018	1	1	01	01	H2256_018_1	8	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2256	018	7	1	01	01	H2256_018_7	7	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	018	7	1	01	01	H2256_018_7	7	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2256	018	7	1	01	01	H2256_018_7	7	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2256	023	0	1	01	01	H2256_023_0	5	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	023	0	1	01	01	H2256_023_0	5	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H2256	023	0	1	01	01	H2256_023_0	5	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H2256	023	0	1	01	01	H2256_023_0	5	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	023	0	1	01	01	H2256_023_0	5	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2256	023	0	1	01	01	H2256_023_0	5	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2256	024	0	1	01	01	H2256_024_0	5	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H2256	024	0	1	01	01	H2256_024_0	5	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H2256	024	0	1	01	01	H2256_024_0	5	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H2261	005	0	1	01	01	H2261_005_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H2261	005	0	1	01	01	H2261_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H2261	005	0	1	01	01	H2261_005_0	4	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2261	005	0	1	01	01	H2261_005_0	4	4	4	1	Specialty Medication	110001	1	1				Specialty Medication	111000000010110000000	30	90								30		30								90	31	Specialty Medication	2	1	Specialty Medication	25	25								25		25	25								25	Specialty Medication																					
H2261	011	0	1	01	01	H2261_011_0	4	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2261	011	0	1	01	01	H2261_011_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2261	011	0	1	01	01	H2261_011_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2261	011	0	1	01	01	H2261_011_0	4	4	4	1	Specialty Medication	110001	1	1				Specialty Medication	111000000010110000000	30	90								30		30								90	31	Specialty Medication	2	1	Specialty Medication	33	33								33		33	33								33	Specialty Medication																					
H2261	011	0	1	01	01	H2261_011_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00								58.00		58.00	116.00								58.00
H2261	011	0	1	01	01	H2261_011_0	4	4	4	3	Specialty Medication	110001	1	1	2			Specialty Medication																							Specialty Medication			Specialty Medication																						Specialty Medication																					
H2261	011	0	1	01	01	H2261_011_0	4	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2261	011	0	1	01	01	H2261_011_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	56.00								28.00
H2291	002	0	1	01	01	H2291_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	2.00	4.00								2.00											2.00
H2291	002	0	1	01	01	H2291_002_0	6	4	4	1	Specialty	100001	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	25	25								25											25	Specialty																					
H2291	002	0	1	01	01	H2291_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	70.00								35.00											35.00
H2291	002	0	1	01	01	H2291_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00											15.00
H2312	004	0	1	01	01	H2312_004_0	10	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2312	004	0	1	01	01	H2312_004_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2312	004	0	1	01	01	H2312_004_0	10	1	4	1	Tier 1	001000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00
H2312	004	0	1	01	01	H2312_004_0	10	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2312	007	0	1	01	01	H2312_007_0	8	1	4	1	Tier 1	001000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00
H2312	007	0	1	01	01	H2312_007_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2312	007	0	1	01	01	H2312_007_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2312	007	0	1	01	01	H2312_007_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2312	009	0	1	01	01	H2312_009_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2312	009	0	1	01	01	H2312_009_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2312	009	0	1	01	01	H2312_009_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2312	009	0	1	01	01	H2312_009_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2312	009	0	1	01	01	H2312_009_0	8	4	4	3	Tier 4	100001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2312	009	0	1	01	01	H2312_009_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2312	009	0	1	01	01	H2312_009_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2312	009	0	1	01	01	H2312_009_0	8	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2312	010	0	1	01	01	H2312_010_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2312	010	0	1	01	01	H2312_010_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2312	010	0	1	01	01	H2312_010_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2312	010	0	1	01	01	H2312_010_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2312	010	0	1	01	01	H2312_010_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2312	010	0	1	01	01	H2312_010_0	8	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2312	010	0	1	01	01	H2312_010_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2312	010	0	1	01	01	H2312_010_0	8	4	4	3	Tier 4	100001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2319	008	3	1	09	04	H2319_008_3	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	008	3	1	09	04	H2319_008_3	9	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	008	3	1	09	04	H2319_008_3	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	008	3	1	09	04	H2319_008_3	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	008	3	1	09	04	H2319_008_3	9	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	008	4	1	09	04	H2319_008_4	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	008	4	1	09	04	H2319_008_4	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	008	4	1	09	04	H2319_008_4	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	008	4	1	09	04	H2319_008_4	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	008	4	1	09	04	H2319_008_4	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	008	5	1	09	04	H2319_008_5	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	008	5	1	09	04	H2319_008_5	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	008	5	1	09	04	H2319_008_5	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	008	5	1	09	04	H2319_008_5	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	008	5	1	09	04	H2319_008_5	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	008	7	1	09	04	H2319_008_7	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	008	7	1	09	04	H2319_008_7	9	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	008	7	1	09	04	H2319_008_7	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	008	7	1	09	04	H2319_008_7	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	008	7	1	09	04	H2319_008_7	9	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	008	8	1	09	04	H2319_008_8	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	008	8	1	09	04	H2319_008_8	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	008	8	1	09	04	H2319_008_8	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	008	8	1	09	04	H2319_008_8	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	008	8	1	09	04	H2319_008_8	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	1	1	09	04	H2319_009_1	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	1	1	09	04	H2319_009_1	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	1	1	09	04	H2319_009_1	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	1	1	09	04	H2319_009_1	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	009	1	1	09	04	H2319_009_1	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	2	1	09	04	H2319_009_2	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	009	2	1	09	04	H2319_009_2	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	2	1	09	04	H2319_009_2	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	2	1	09	04	H2319_009_2	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	2	1	09	04	H2319_009_2	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	3	1	09	04	H2319_009_3	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	3	1	09	04	H2319_009_3	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	3	1	09	04	H2319_009_3	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	009	3	1	09	04	H2319_009_3	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	3	1	09	04	H2319_009_3	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	4	1	09	04	H2319_009_4	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	4	1	09	04	H2319_009_4	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	4	1	09	04	H2319_009_4	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	4	1	09	04	H2319_009_4	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	4	1	09	04	H2319_009_4	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	009	5	1	09	04	H2319_009_5	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	5	1	09	04	H2319_009_5	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	5	1	09	04	H2319_009_5	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	5	1	09	04	H2319_009_5	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	5	1	09	04	H2319_009_5	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	009	6	1	09	04	H2319_009_6	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	009	6	1	09	04	H2319_009_6	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	009	6	1	09	04	H2319_009_6	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	009	6	1	09	04	H2319_009_6	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	009	6	1	09	04	H2319_009_6	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	1	1	09	04	H2319_010_1	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	1	1	09	04	H2319_010_1	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	1	1	09	04	H2319_010_1	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	1	1	09	04	H2319_010_1	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	1	1	09	04	H2319_010_1	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	1	1	09	04	H2319_010_1	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	1	1	09	04	H2319_010_1	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	1	1	09	04	H2319_010_1	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	1	1	09	04	H2319_010_1	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	1	1	09	04	H2319_010_1	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	2	1	09	04	H2319_010_2	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	2	1	09	04	H2319_010_2	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	2	1	09	04	H2319_010_2	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	2	1	09	04	H2319_010_2	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	2	1	09	04	H2319_010_2	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	2	1	09	04	H2319_010_2	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	2	1	09	04	H2319_010_2	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	2	1	09	04	H2319_010_2	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	2	1	09	04	H2319_010_2	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	2	1	09	04	H2319_010_2	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	3	1	09	04	H2319_010_3	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	3	1	09	04	H2319_010_3	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	3	1	09	04	H2319_010_3	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	3	1	09	04	H2319_010_3	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	3	1	09	04	H2319_010_3	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	3	1	09	04	H2319_010_3	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	3	1	09	04	H2319_010_3	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	3	1	09	04	H2319_010_3	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	3	1	09	04	H2319_010_3	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	3	1	09	04	H2319_010_3	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	4	1	09	04	H2319_010_4	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	4	1	09	04	H2319_010_4	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	4	1	09	04	H2319_010_4	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	4	1	09	04	H2319_010_4	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	4	1	09	04	H2319_010_4	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	4	1	09	04	H2319_010_4	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	4	1	09	04	H2319_010_4	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	4	1	09	04	H2319_010_4	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	4	1	09	04	H2319_010_4	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	4	1	09	04	H2319_010_4	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	5	1	09	04	H2319_010_5	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	5	1	09	04	H2319_010_5	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	5	1	09	04	H2319_010_5	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	5	1	09	04	H2319_010_5	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	5	1	09	04	H2319_010_5	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	5	1	09	04	H2319_010_5	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	5	1	09	04	H2319_010_5	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	5	1	09	04	H2319_010_5	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	5	1	09	04	H2319_010_5	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	5	1	09	04	H2319_010_5	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	6	1	09	04	H2319_010_6	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	010	6	1	09	04	H2319_010_6	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	010	6	1	09	04	H2319_010_6	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	010	6	1	09	04	H2319_010_6	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	010	6	1	09	04	H2319_010_6	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	010	6	1	09	04	H2319_010_6	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	010	6	1	09	04	H2319_010_6	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	010	6	1	09	04	H2319_010_6	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	010	6	1	09	04	H2319_010_6	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	010	6	1	09	04	H2319_010_6	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	1	1	09	04	H2319_011_1	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	1	1	09	04	H2319_011_1	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	1	1	09	04	H2319_011_1	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	1	1	09	04	H2319_011_1	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	1	1	09	04	H2319_011_1	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	1	1	09	04	H2319_011_1	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	1	1	09	04	H2319_011_1	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	1	1	09	04	H2319_011_1	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	011	1	1	09	04	H2319_011_1	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	1	1	09	04	H2319_011_1	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	2	1	09	04	H2319_011_2	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	2	1	09	04	H2319_011_2	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	2	1	09	04	H2319_011_2	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	2	1	09	04	H2319_011_2	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	2	1	09	04	H2319_011_2	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	011	2	1	09	04	H2319_011_2	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	2	1	09	04	H2319_011_2	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	2	1	09	04	H2319_011_2	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	2	1	09	04	H2319_011_2	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	2	1	09	04	H2319_011_2	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	3	1	09	04	H2319_011_3	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	3	1	09	04	H2319_011_3	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	3	1	09	04	H2319_011_3	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	011	3	1	09	04	H2319_011_3	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	3	1	09	04	H2319_011_3	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	3	1	09	04	H2319_011_3	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	3	1	09	04	H2319_011_3	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	3	1	09	04	H2319_011_3	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	3	1	09	04	H2319_011_3	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	3	1	09	04	H2319_011_3	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	4	1	09	04	H2319_011_4	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	4	1	09	04	H2319_011_4	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	4	1	09	04	H2319_011_4	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	4	1	09	04	H2319_011_4	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	4	1	09	04	H2319_011_4	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	4	1	09	04	H2319_011_4	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	4	1	09	04	H2319_011_4	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	4	1	09	04	H2319_011_4	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	011	4	1	09	04	H2319_011_4	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	4	1	09	04	H2319_011_4	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	5	1	09	04	H2319_011_5	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	5	1	09	04	H2319_011_5	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	5	1	09	04	H2319_011_5	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	5	1	09	04	H2319_011_5	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	5	1	09	04	H2319_011_5	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2319	011	5	1	09	04	H2319_011_5	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	5	1	09	04	H2319_011_5	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	5	1	09	04	H2319_011_5	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	5	1	09	04	H2319_011_5	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	5	1	09	04	H2319_011_5	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	6	1	09	04	H2319_011_6	8	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	6	1	09	04	H2319_011_6	8	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
H2319	011	6	1	09	04	H2319_011_6	8	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
H2319	011	6	1	09	04	H2319_011_6	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2319	011	6	1	09	04	H2319_011_6	8	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
H2319	011	6	1	09	04	H2319_011_6	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2319	011	6	1	09	04	H2319_011_6	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H2319	011	6	1	09	04	H2319_011_6	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
H2319	011	6	1	09	04	H2319_011_6	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
H2319	011	6	1	09	04	H2319_011_6	8	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H2320	007	0	1	02	01	H2320_007_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	007	0	1	02	01	H2320_007_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	007	0	1	02	01	H2320_007_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	007	0	1	02	01	H2320_007_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	008	0	1	02	01	H2320_008_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	008	0	1	02	01	H2320_008_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	008	0	1	02	01	H2320_008_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	008	0	1	02	01	H2320_008_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	009	0	1	02	01	H2320_009_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	009	0	1	02	01	H2320_009_0	5	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	009	0	1	02	01	H2320_009_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	009	0	1	02	01	H2320_009_0	5	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	009	0	1	02	01	H2320_009_0	5	4	4	3	Specialty Tier	010010	1	1	2			Specialty Tier																							Specialty Tier			Specialty Tier																						Specialty Tier																					
H2320	009	0	1	02	01	H2320_009_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2320	009	0	1	02	01	H2320_009_0	5	2	4	3	Preferred Brand on Formulary	000001	1	2	2			Preferred Brand on Formulary																							Preferred Brand on Formulary			Preferred Brand on Formulary																						Preferred Brand on Formulary																					
H2320	009	0	1	02	01	H2320_009_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	010	0	1	02	01	H2320_010_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	010	0	1	02	01	H2320_010_0	5	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	010	0	1	02	01	H2320_010_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	010	0	1	02	01	H2320_010_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2320	010	0	1	02	01	H2320_010_0	5	2	4	3	Preferred Brand on Formulary	000001	1	2	2			Preferred Brand on Formulary																							Preferred Brand on Formulary			Preferred Brand on Formulary																						Preferred Brand on Formulary																					
H2320	010	0	1	02	01	H2320_010_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	010	0	1	02	01	H2320_010_0	5	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	010	0	1	02	01	H2320_010_0	5	4	4	3	Specialty Tier	010010	1	1	2			Specialty Tier																							Specialty Tier			Specialty Tier																						Specialty Tier																					
H2320	011	0	1	02	01	H2320_011_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	011	0	1	02	01	H2320_011_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	011	0	1	02	01	H2320_011_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	011	0	1	02	01	H2320_011_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	012	0	1	02	01	H2320_012_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	012	0	1	02	01	H2320_012_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	012	0	1	02	01	H2320_012_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	012	0	1	02	01	H2320_012_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	013	0	1	02	01	H2320_013_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	013	0	1	02	01	H2320_013_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	013	0	1	02	01	H2320_013_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	013	0	1	02	01	H2320_013_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	014	0	1	02	01	H2320_014_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	014	0	1	02	01	H2320_014_0	5	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	014	0	1	02	01	H2320_014_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	014	0	1	02	01	H2320_014_0	5	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	014	0	1	02	01	H2320_014_0	5	4	4	3	Specialty Tier	010010	1	1	2			Specialty Tier																							Specialty Tier			Specialty Tier																						Specialty Tier																					
H2320	014	0	1	02	01	H2320_014_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2320	014	0	1	02	01	H2320_014_0	5	2	4	3	Preferred Brand on Formulary	000001	1	2	2			Preferred Brand on Formulary																							Preferred Brand on Formulary			Preferred Brand on Formulary																						Preferred Brand on Formulary																					
H2320	014	0	1	02	01	H2320_014_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	015	0	1	02	01	H2320_015_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	015	0	1	02	01	H2320_015_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	015	0	1	02	01	H2320_015_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	015	0	1	02	01	H2320_015_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	016	0	1	02	01	H2320_016_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	016	0	1	02	01	H2320_016_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	016	0	1	02	01	H2320_016_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	016	0	1	02	01	H2320_016_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	017	0	1	02	01	H2320_017_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	017	0	1	02	01	H2320_017_0	5	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2320	017	0	1	02	01	H2320_017_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	017	0	1	02	01	H2320_017_0	5	2	4	3	Preferred Brand on Formulary	000001	1	2	2			Preferred Brand on Formulary																							Preferred Brand on Formulary			Preferred Brand on Formulary																						Preferred Brand on Formulary																					
H2320	017	0	1	02	01	H2320_017_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2320	017	0	1	02	01	H2320_017_0	5	4	4	3	Specialty Tier	010010	1	1	2			Specialty Tier																							Specialty Tier			Specialty Tier																						Specialty Tier																					
H2320	017	0	1	02	01	H2320_017_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	017	0	1	02	01	H2320_017_0	5	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	018	0	1	02	01	H2320_018_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
H2320	018	0	1	02	01	H2320_018_0	4	2	4	1	Preferred Brand on Formulary	000001	1	2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	30.00	90.00								30.00			75.00								30.00
H2320	018	0	1	02	01	H2320_018_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			20.00								8.00
H2320	018	0	1	02	01	H2320_018_0	4	4	4	1	Specialty Tier	010010	1	1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	25									25											25	Specialty Tier																					
H2322	001	0	1	04	01	H2322_001_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2322	001	0	1	04	01	H2322_001_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2322	001	0	1	04	01	H2322_001_0	8	1	4	1	Tier 1	001000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00
H2322	001	0	1	04	01	H2322_001_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2322	004	0	1	04	01	H2322_004_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2322	004	0	1	04	01	H2322_004_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2322	004	0	1	04	01	H2322_004_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2322	004	0	1	04	01	H2322_004_0	8	4	4	3	Tier 4	100001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2322	004	0	1	04	01	H2322_004_0	8	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2322	004	0	1	04	01	H2322_004_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2322	004	0	1	04	01	H2322_004_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2322	004	0	1	04	01	H2322_004_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2322	006	0	1	04	01	H2322_006_0	9	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2322	006	0	1	04	01	H2322_006_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2322	006	0	1	04	01	H2322_006_0	9	1	4	1	Tier 1	001000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00
H2322	006	0	1	04	01	H2322_006_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2322	007	0	1	04	01	H2322_007_0	8	4	4	3	Tier 4	100001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2322	007	0	1	04	01	H2322_007_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2322	007	0	1	04	01	H2322_007_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2322	007	0	1	04	01	H2322_007_0	8	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2322	007	0	1	04	01	H2322_007_0	8	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
H2322	007	0	1	04	01	H2322_007_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
H2322	007	0	1	04	01	H2322_007_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
H2322	007	0	1	04	01	H2322_007_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
H2323	006	0	1	01	01	H2323_006_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H2323	006	0	1	01	01	H2323_006_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2323	006	0	1	01	01	H2323_006_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H2323	007	0	1	01	01	H2323_007_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H2323	007	0	1	01	01	H2323_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2323	007	0	1	01	01	H2323_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H2354	001	0	1	01	01	H2354_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	1	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00
H2354	001	0	1	01	01	H2354_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00		35.00	70.00								35.00
H2354	001	0	1	01	01	H2354_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00		70.00	140.00								70.00
H2354	001	0	1	01	01	H2354_001_0	5	4	4	1	Injectable and Miscellaneous Drugs	110001	1	2				Injectable and Miscellaneous Drugs	110000000010000000000	34									34											34	Injectable and Miscellaneous Drugs	1	4	Injectable and Miscellaneous Drugs	25									25											25	Injectable and Miscellaneous Drugs	125.00									125.00											125.00
H2354	013	0	1	01	01	H2354_013_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	1	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00
H2354	013	0	1	01	01	H2354_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00		35.00	70.00								35.00
H2354	013	0	1	01	01	H2354_013_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00		70.00	140.00								70.00
H2354	013	0	1	01	01	H2354_013_0	5	4	4	1	Injectable and Miscellaneous Drugs	110001	1	2				Injectable and Miscellaneous Drugs	110000000010000000000	34									34											34	Injectable and Miscellaneous Drugs	1	4	Injectable and Miscellaneous Drugs	25									25											25	Injectable and Miscellaneous Drugs	125.00									125.00											125.00
H2406	001	0	1	04	01	H2406_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2406	001	0	1	04	01	H2406_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2406	001	0	1	04	01	H2406_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2406	001	0	1	04	01	H2406_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2409	006	0	1	09	04	H2409_006_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	82.00	246.00								82.00			164.00								82.00
H2409	006	0	1	09	04	H2409_006_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			80.00								40.00
H2409	006	0	1	09	04	H2409_006_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H2409	006	0	1	09	04	H2409_006_0	10	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2410	015	0	1	09	04	H2410_015_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H2410	015	0	1	09	04	H2410_015_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			80.00								40.00
H2410	015	0	1	09	04	H2410_015_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	82.00	246.00								82.00			164.00								82.00
H2410	015	0	1	09	04	H2410_015_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2411	002	0	1	04	01	H2411_002_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H2411	002	0	1	04	01	H2411_002_0	7	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H2411	002	0	1	04	01	H2411_002_0	7	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00	110.00							55.00		55.00	165.00	110.00							55.00
H2425	001	0	1	01	01	H2425_001_0	6	1	4	1	Level 1: Generic	010000	1	2				Level 1: Generic	110000000010000000000	34									34											34	Level 1: Generic	2	1	Level 1: Generic	0									0											0	Level 1: Generic																					
H2425	001	0	1	01	01	H2425_001_0	6	2	4	1	Level 2: Preferred Brand	000001	1	2				Level 2: Preferred Brand	110000000010000000000	34									34											34	Level 2: Preferred Brand	2	1	Level 2: Preferred Brand	25									25											25	Level 2: Preferred Brand																					
H2425	001	0	1	01	01	H2425_001_0	6	3	4	1	Level 3: Brand	000010	1	2				Level 3: Brand	110000000010000000000	34									34											34	Level 3: Brand	2	1	Level 3: Brand	25									25											25	Level 3: Brand																					
H2425	001	0	1	01	01	H2425_001_0	6	4	4	3	Specialty	110011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2425	001	0	1	01	01	H2425_001_0	6	1	4	3	Level 1: Generic	010000	1	2	1		1	Level 1: Generic	110000000010000000000	34									34											34	Level 1: Generic	2	1	Level 1: Generic	0									0											0	Level 1: Generic																					
H2425	001	0	1	01	01	H2425_001_0	6	2	4	3	Level 2: Preferred Brand	000001	1	2	2			Level 2: Preferred Brand																							Level 2: Preferred Brand			Level 2: Preferred Brand																						Level 2: Preferred Brand																					
H2425	001	0	1	01	01	H2425_001_0	6	3	4	3	Level 3: Brand	000010	1	2	2			Level 3: Brand																							Level 3: Brand			Level 3: Brand																						Level 3: Brand																					
H2425	001	0	1	01	01	H2425_001_0	6	4	4	1	Specialty	110011	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2450	001	0	1	18	06	H2450_001_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	001	0	1	18	06	H2450_001_0	12	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	001	0	1	18	06	H2450_001_0	12	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	001	0	1	18	06	H2450_001_0	12	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	002	0	1	18	06	H2450_002_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	002	0	1	18	06	H2450_002_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	002	0	1	18	06	H2450_002_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	002	0	1	18	06	H2450_002_0	11	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	005	0	1	18	06	H2450_005_0	12	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	005	0	1	18	06	H2450_005_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	005	0	1	18	06	H2450_005_0	12	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	005	0	1	18	06	H2450_005_0	12	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	005	0	1	18	06	H2450_005_0	12	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	005	0	1	18	06	H2450_005_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	005	0	1	18	06	H2450_005_0	12	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	005	0	1	18	06	H2450_005_0	12	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	006	0	1	18	06	H2450_006_0	11	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	006	0	1	18	06	H2450_006_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	006	0	1	18	06	H2450_006_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	006	0	1	18	06	H2450_006_0	11	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	006	0	1	18	06	H2450_006_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	006	0	1	18	06	H2450_006_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	006	0	1	18	06	H2450_006_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	006	0	1	18	06	H2450_006_0	11	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	007	0	1	18	06	H2450_007_0	9	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H2450	007	0	1	18	06	H2450_007_0	9	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			72.00								36.00
H2450	007	0	1	18	06	H2450_007_0	9	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	007	0	1	18	06	H2450_007_0	9	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	008	0	1	18	06	H2450_008_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	008	0	1	18	06	H2450_008_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	008	0	1	18	06	H2450_008_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	008	0	1	18	06	H2450_008_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	009	0	1	18	06	H2450_009_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	009	0	1	18	06	H2450_009_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	009	0	1	18	06	H2450_009_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	009	0	1	18	06	H2450_009_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	009	0	1	18	06	H2450_009_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	009	0	1	18	06	H2450_009_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	009	0	1	18	06	H2450_009_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	009	0	1	18	06	H2450_009_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	010	0	1	18	06	H2450_010_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	010	0	1	18	06	H2450_010_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	010	0	1	18	06	H2450_010_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	010	0	1	18	06	H2450_010_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	010	0	1	18	06	H2450_010_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	010	0	1	18	06	H2450_010_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	010	0	1	18	06	H2450_010_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	010	0	1	18	06	H2450_010_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	011	0	1	18	06	H2450_011_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	011	0	1	18	06	H2450_011_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	011	0	1	18	06	H2450_011_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	011	0	1	18	06	H2450_011_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	012	0	1	18	06	H2450_012_0	6	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	012	0	1	18	06	H2450_012_0	6	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	012	0	1	18	06	H2450_012_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	012	0	1	18	06	H2450_012_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	013	0	1	18	06	H2450_013_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	013	0	1	18	06	H2450_013_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	013	0	1	18	06	H2450_013_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	013	0	1	18	06	H2450_013_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	013	0	1	18	06	H2450_013_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	013	0	1	18	06	H2450_013_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	013	0	1	18	06	H2450_013_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	013	0	1	18	06	H2450_013_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	014	0	1	18	06	H2450_014_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	014	0	1	18	06	H2450_014_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2450	014	0	1	18	06	H2450_014_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	014	0	1	18	06	H2450_014_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	015	0	1	18	06	H2450_015_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	015	0	1	18	06	H2450_015_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2450	015	0	1	18	06	H2450_015_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2450	015	0	1	18	06	H2450_015_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H2450	015	0	1	18	06	H2450_015_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	71.00	213.00								71.00			142.00								71.00
H2450	015	0	1	18	06	H2450_015_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2450	015	0	1	18	06	H2450_015_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00			26.00								13.00
H2450	015	0	1	18	06	H2450_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H2459	002	0	1	02	01	H2459_002_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	002	0	1	02	01	H2459_002_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H2459	002	0	1	02	01	H2459_002_0	5	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H2459	002	0	1	02	01	H2459_002_0	5	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2459	002	0	1	02	01	H2459_002_0	5	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	002	0	1	02	01	H2459_002_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2459	002	0	1	02	01	H2459_002_0	5	3	4	3	Tier 3	000010	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2459	002	0	1	02	01	H2459_002_0	5	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2459	006	0	1	02	01	H2459_006_0	5	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H2459	006	0	1	02	01	H2459_006_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H2459	006	0	1	02	01	H2459_006_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	006	0	1	02	01	H2459_006_0	5	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2459	006	0	1	02	01	H2459_006_0	5	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	006	0	1	02	01	H2459_006_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2459	006	0	1	02	01	H2459_006_0	5	3	4	3	Tier 3	000010	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2459	006	0	1	02	01	H2459_006_0	5	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2459	013	0	1	02	01	H2459_013_0	5	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H2459	013	0	1	02	01	H2459_013_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H2459	013	0	1	02	01	H2459_013_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	013	0	1	02	01	H2459_013_0	5	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2459	014	0	1	02	01	H2459_014_0	4	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H2459	014	0	1	02	01	H2459_014_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H2459	014	0	1	02	01	H2459_014_0	4	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H2459	014	0	1	02	01	H2459_014_0	4	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2459	017	0	1	01	01	H2459_017_0	4	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			10.00								5.00
H2459	017	0	1	01	01	H2459_017_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2459	017	0	1	01	01	H2459_017_0	4	3	4	3	Tier 3	000010	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2459	017	0	1	01	01	H2459_017_0	4	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2459	017	0	1	01	01	H2459_017_0	4	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H2459	017	0	1	01	01	H2459_017_0	4	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2459	017	0	1	01	01	H2459_017_0	4	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			10.00								5.00
H2459	017	0	1	01	01	H2459_017_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H2462	008	0	1	18	06	H2462_008_0	5	2	3	1	Formulary Brand	000010		2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	36.00	108.00								36.00		36.00	72.00								36.00
H2462	008	0	1	18	06	H2462_008_0	5	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	008	0	1	18	06	H2462_008_0	5	3	3	1	Formulary Specialty	010010		1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	009	0	1	18	06	H2462_009_0	4	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	009	0	1	18	06	H2462_009_0	4	2	4	1	Formulary Brand	000010	1	2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	45.00	135.00								45.00		45.00	90.00								45.00
H2462	009	0	1	18	06	H2462_009_0	4	3	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	011	0	1	18	06	H2462_011_0	4	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	18.00								9.00
H2462	011	0	1	18	06	H2462_011_0	4	2	3	1	Formulary Brand	000010		2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	34.00	102.00								34.00		34.00	68.00								34.00
H2462	011	0	1	18	06	H2462_011_0	4	3	3	1	Formulary Specialty	010010		1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	012	0	1	18	06	H2462_012_0	3	2	4	1	Formulary Brand	000010	1	2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	45.00	135.00								45.00		45.00	90.00								45.00
H2462	012	0	1	18	06	H2462_012_0	3	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	012	0	1	18	06	H2462_012_0	3	3	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	013	0	1	18	06	H2462_013_0	3	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	013	0	1	18	06	H2462_013_0	3	2	4	1	Formulary Brand	000010	1	2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	36.00	108.00								36.00		36.00	72.00								36.00
H2462	013	0	1	18	06	H2462_013_0	3	3	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	013	0	1	18	06	H2462_013_0	3	1	4	3	Formulary Generic	010000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	013	0	1	18	06	H2462_013_0	3	2	4	3	Formulary Brand	000010	1	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H2462	013	0	1	18	06	H2462_013_0	3	3	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
H2462	014	0	1	18	06	H2462_014_0	2	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	014	0	1	18	06	H2462_014_0	2	2	4	1	Formulary Brand	000010	1	2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	36.00	108.00								36.00		36.00	72.00								36.00
H2462	014	0	1	18	06	H2462_014_0	2	3	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
H2462	014	0	1	18	06	H2462_014_0	2	1	4	3	Formulary Generic	010000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	20.00								10.00
H2462	014	0	1	18	06	H2462_014_0	2	2	4	3	Formulary Brand	000010	1	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H2462	014	0	1	18	06	H2462_014_0	2	3	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
H2481	004	0	1	04	01	H2481_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H2481	004	0	1	04	01	H2481_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H2481	004	0	1	04	01	H2481_004_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H2481	004	0	1	04	01	H2481_004_0	7	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2481	006	0	1	04	01	H2481_006_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H2481	006	0	1	04	01	H2481_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H2481	006	0	1	04	01	H2481_006_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H2481	006	0	1	04	01	H2481_006_0	7	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2486	002	0	1	01	01	H2486_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2486	002	0	1	01	01	H2486_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H2486	002	0	1	01	01	H2486_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2486	002	0	1	01	01	H2486_002_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2486	002	0	1	01	01	H2486_002_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2486	002	0	1	01	01	H2486_002_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H2486	002	0	1	01	01	H2486_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2486	002	0	1	01	01	H2486_002_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2491	001	0	1	01	01	H2491_001_0	9	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H2491	001	0	1	01	01	H2491_001_0	9	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H2491	001	0	1	01	01	H2491_001_0	9	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H2491	001	0	1	01	01	H2491_001_0	9	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H2491	002	0	1	01	01	H2491_002_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H2491	002	0	1	01	01	H2491_002_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2491	002	0	1	01	01	H2491_002_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2491	002	0	1	01	01	H2491_002_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H2491	002	0	1	01	01	H2491_002_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H2491	002	0	1	01	01	H2491_002_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2491	002	0	1	01	01	H2491_002_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H2491	002	0	1	01	01	H2491_002_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H2542	001	0	1	04	01	H2542_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2542	001	0	1	04	01	H2542_001_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2542	001	0	1	04	01	H2542_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2542	001	0	1	04	01	H2542_001_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2542	001	0	1	04	01	H2542_001_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2542	001	0	1	04	01	H2542_001_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2542	001	0	1	04	01	H2542_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2542	001	0	1	04	01	H2542_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2542	002	0	1	04	01	H2542_002_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2542	002	0	1	04	01	H2542_002_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2542	002	0	1	04	01	H2542_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2542	002	0	1	04	01	H2542_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2542	002	0	1	04	01	H2542_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H2542	002	0	1	04	01	H2542_002_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2542	002	0	1	04	01	H2542_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2542	002	0	1	04	01	H2542_002_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2610	005	0	1	01	01	H2610_005_0	8	3	4	1	Tier 3 non-preferred brand	100000	1	2				Tier 3 non-preferred brand	111000000010110000000	31	93								31		31								93	34	Tier 3 non-preferred brand	2	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	177.00								59.00		59.00	118.00								59.00
H2610	005	0	1	01	01	H2610_005_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H2610	005	0	1	01	01	H2610_005_0	8	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H2610	005	0	1	01	01	H2610_005_0	8	4	4	1	Tier 4 specialty	100011	1	1				Tier 4 specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 specialty	2	1	Tier 4 specialty	20	20								20		20	20								20	Tier 4 specialty																					
H2610	006	0	1	01	01	H2610_006_0	8	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H2610	006	0	1	01	01	H2610_006_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H2610	006	0	1	01	01	H2610_006_0	8	3	4	1	Tier 3 Non-Preferred Brand	100000	1	2				Tier 3 Non-Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	50.00	150.00								50.00		50.00	100.00								50.00
H2610	006	0	1	01	01	H2610_006_0	8	4	4	1	Tier 4 Specialty	100011	1	1				Tier 4 Specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 Specialty	2	1	Tier 4 Specialty	20	20								20		20	20								20	Tier 4 Specialty																					
H2610	010	0	1	01	01	H2610_010_0	8	3	4	1	Tier 3 non-preferred brand	100000	1	2				Tier 3 non-preferred brand	111000000010110000000	31	93								31		31								93	34	Tier 3 non-preferred brand	2	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	177.00								59.00		59.00	118.00								59.00
H2610	010	0	1	01	01	H2610_010_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H2610	010	0	1	01	01	H2610_010_0	8	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H2610	010	0	1	01	01	H2610_010_0	8	4	4	1	Tier 4 specialty	100011	1	1				Tier 4 specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 specialty	2	1	Tier 4 specialty	20	20								20		20	20								20	Tier 4 specialty																					
H2611	001	0	1	04	01	H2611_001_0	9	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	001	0	1	04	01	H2611_001_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	001	0	1	04	01	H2611_001_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	001	0	1	04	01	H2611_001_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	002	0	1	04	01	H2611_002_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	002	0	1	04	01	H2611_002_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	002	0	1	04	01	H2611_002_0	9	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	002	0	1	04	01	H2611_002_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	002	0	1	04	01	H2611_002_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	002	0	1	04	01	H2611_002_0	9	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2611	002	0	1	04	01	H2611_002_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2611	002	0	1	04	01	H2611_002_0	9	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2611	003	0	1	04	01	H2611_003_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	003	0	1	04	01	H2611_003_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2611	003	0	1	04	01	H2611_003_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2611	003	0	1	04	01	H2611_003_0	8	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2611	003	0	1	04	01	H2611_003_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	003	0	1	04	01	H2611_003_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	003	0	1	04	01	H2611_003_0	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	003	0	1	04	01	H2611_003_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	008	0	1	04	01	H2611_008_0	8	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	008	0	1	04	01	H2611_008_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	008	0	1	04	01	H2611_008_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	008	0	1	04	01	H2611_008_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	012	0	1	04	01	H2611_012_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	012	0	1	04	01	H2611_012_0	6	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	012	0	1	04	01	H2611_012_0	6	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	012	0	1	04	01	H2611_012_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	012	0	1	04	01	H2611_012_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	012	0	1	04	01	H2611_012_0	6	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2611	012	0	1	04	01	H2611_012_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2611	012	0	1	04	01	H2611_012_0	6	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2611	016	0	1	04	01	H2611_016_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H2611	016	0	1	04	01	H2611_016_0	7	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H2611	016	0	1	04	01	H2611_016_0	7	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H2611	016	0	1	04	01	H2611_016_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2611	016	0	1	04	01	H2611_016_0	7	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2611	016	0	1	04	01	H2611_016_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2611	016	0	1	04	01	H2611_016_0	7	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2611	016	0	1	04	01	H2611_016_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2613	004	0	1	09	04	H2613_004_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H2613	004	0	1	09	04	H2613_004_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H2613	004	0	1	09	04	H2613_004_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H2613	004	0	1	09	04	H2613_004_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H2613	004	0	1	09	04	H2613_004_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H2613	004	0	1	09	04	H2613_004_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H2613	004	0	1	09	04	H2613_004_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H2613	004	0	1	09	04	H2613_004_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H2613	004	0	1	09	04	H2613_004_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H2613	004	0	1	09	04	H2613_004_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H2643	001	0	1	01	01	H2643_001_0	7	1	4	3	Tier 1 - Preferred Generic	001100	1	2	1		1	Tier 1 - Preferred Generic	111100000010010000000	30	90	60							30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00	0.00							0.00			0.00								0.00
H2643	001	0	1	01	01	H2643_001_0	7	1	4	1	Tier 1 - Preferred Generic	001100	1	2				Tier 1 - Preferred Generic	111100000010010000000	30	90	60							30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00	0.00							0.00			0.00								0.00
H2643	001	0	1	01	01	H2643_001_0	7	2	4	1	Tier 2 - Other	100001	1	2				Tier 2 - Other	111100000010010000000	30	90	60							30										90	31	Tier 2 - Other	2	2	Tier 2 - Other																						Tier 2 - Other	45.00	135.00	135.00							45.00			135.00								45.00
H2643	001	0	1	01	01	H2643_001_0	7	2	4	3	Tier 2 - Other	100001	1	2	2			Tier 2 - Other																							Tier 2 - Other			Tier 2 - Other																						Tier 2 - Other																					
H2648	003	0	1	09	04	H2648_003_0	5	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	33	33								33		33	27								33	Specialty Injectables																					
H2648	003	0	1	09	04	H2648_003_0	5	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H2648	003	0	1	09	04	H2648_003_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H2648	003	0	1	09	04	H2648_003_0	5	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.50	25.50								8.50		8.50	21.25								8.50
H2648	004	0	1	09	04	H2648_004_0	5	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	25	25								25		25	20								25	Specialty Injectables																					
H2648	004	0	1	09	04	H2648_004_0	5	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H2648	004	0	1	09	04	H2648_004_0	5	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H2648	004	0	1	09	04	H2648_004_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H2649	004	0	1	01	01	H2649_004_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	004	0	1	01	01	H2649_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	004	0	1	01	01	H2649_004_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	004	0	1	01	01	H2649_004_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	004	0	1	01	01	H2649_004_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2649	004	0	1	01	01	H2649_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	004	0	1	01	01	H2649_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	004	0	1	01	01	H2649_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2649	011	0	1	01	01	H2649_011_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	011	0	1	01	01	H2649_011_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	011	0	1	01	01	H2649_011_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	011	0	1	01	01	H2649_011_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	011	0	1	01	01	H2649_011_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	011	0	1	01	01	H2649_011_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2649	011	0	1	01	01	H2649_011_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2649	011	0	1	01	01	H2649_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	015	0	1	01	01	H2649_015_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H2649	015	0	1	01	01	H2649_015_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2649	015	0	1	01	01	H2649_015_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H2649	015	0	1	01	01	H2649_015_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H2649	015	0	1	01	01	H2649_015_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H2649	015	0	1	01	01	H2649_015_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H2649	015	0	1	01	01	H2649_015_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H2649	015	0	1	01	01	H2649_015_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H2649	016	0	1	01	01	H2649_016_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2649	016	0	1	01	01	H2649_016_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	016	0	1	01	01	H2649_016_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	016	0	1	01	01	H2649_016_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	016	0	1	01	01	H2649_016_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00					28.00	70.00		28.00	84.00		28.00
H2649	016	0	1	01	01	H2649_016_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H2649	016	0	1	01	01	H2649_016_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H2649	016	0	1	01	01	H2649_016_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H2654	004	0	1	01	01	H2654_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2654	004	0	1	01	01	H2654_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H2654	004	0	1	01	01	H2654_004_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H2654	004	0	1	01	01	H2654_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2654	010	0	1	02	01	H2654_010_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2654	010	0	1	02	01	H2654_010_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H2654	010	0	1	02	01	H2654_010_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H2654	010	0	1	02	01	H2654_010_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2654	013	0	1	02	01	H2654_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2654	013	0	1	02	01	H2654_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H2654	013	0	1	02	01	H2654_013_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H2654	013	0	1	02	01	H2654_013_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2654	026	0	1	01	01	H2654_026_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2654	026	0	1	01	01	H2654_026_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2654	026	0	1	01	01	H2654_026_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2654	026	0	1	01	01	H2654_026_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2654	027	0	1	01	01	H2654_027_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2654	027	0	1	01	01	H2654_027_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2654	027	0	1	01	01	H2654_027_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2654	027	0	1	01	01	H2654_027_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2663	002	0	1	01	01	H2663_002_0	12	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H2663	002	0	1	01	01	H2663_002_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2663	002	0	1	01	01	H2663_002_0	12	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H2663	002	0	1	01	01	H2663_002_0	12	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2663	002	0	1	01	01	H2663_002_0	12	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H2663	002	0	1	01	01	H2663_002_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00			70.00								35.00
H2663	002	0	1	01	01	H2663_002_0	12	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H2663	002	0	1	01	01	H2663_002_0	12	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	005	0	1	01	01	H2663_005_0	11	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	005	0	1	01	01	H2663_005_0	11	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	005	0	1	01	01	H2663_005_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	68.00								34.00			68.00								34.00
H2663	005	0	1	01	01	H2663_005_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	4.00								2.00			4.00								2.00
H2663	006	0	1	01	01	H2663_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	68.00								34.00			68.00								34.00
H2663	006	0	1	01	01	H2663_006_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	006	0	1	01	01	H2663_006_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	4.00								2.00			4.00								2.00
H2663	006	0	1	01	01	H2663_006_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	007	0	1	01	01	H2663_007_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	68.00								34.00			68.00								34.00
H2663	007	0	1	01	01	H2663_007_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	4.00								2.00			4.00								2.00
H2663	007	0	1	01	01	H2663_007_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	007	0	1	01	01	H2663_007_0	10	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	008	0	1	01	01	H2663_008_0	8	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H2663	008	0	1	01	01	H2663_008_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	78.00								39.00			78.00								39.00
H2663	008	0	1	01	01	H2663_008_0	8	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	008	0	1	01	01	H2663_008_0	8	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	008	0	1	01	01	H2663_008_0	8	5	4	3	Diabetic Needs	001001	3	2	1		1	Diabetic Needs	111000000010010000000	30	90								30										90	31	Diabetic Needs	2	2	Diabetic Needs																						Diabetic Needs	0.00	0.00								0.00			0.00								0.00
H2663	008	0	1	01	01	H2663_008_0	8	1	4	3	Preferred Generic	001000	3	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H2663	008	0	1	01	01	H2663_008_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2663	008	0	1	01	01	H2663_008_0	8	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H2663	008	0	1	01	01	H2663_008_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2663	008	0	1	01	01	H2663_008_0	8	5	4	1	Diabetic Needs	001001	3	2				Diabetic Needs	111000000010010000000	30	90								30										90	31	Diabetic Needs	2	2	Diabetic Needs																						Diabetic Needs	0.00	0.00								0.00			0.00								0.00
H2663	009	0	1	01	01	H2663_009_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2663	009	0	1	01	01	H2663_009_0	8	1	4	3	Preferred Generic	001000	3	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H2663	009	0	1	01	01	H2663_009_0	8	5	4	1	Diabetic Needs	001001	3	2				Diabetic Needs	111000000010010000000	30	90								30										90	31	Diabetic Needs	2	2	Diabetic Needs																						Diabetic Needs	0.00	0.00								0.00			0.00								0.00
H2663	009	0	1	01	01	H2663_009_0	8	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	009	0	1	01	01	H2663_009_0	8	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	009	0	1	01	01	H2663_009_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	78.00								39.00			78.00								39.00
H2663	009	0	1	01	01	H2663_009_0	8	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H2663	009	0	1	01	01	H2663_009_0	8	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H2663	009	0	1	01	01	H2663_009_0	8	5	4	3	Diabetic Needs	001001	3	2	1		1	Diabetic Needs	111000000010010000000	30	90								30										90	31	Diabetic Needs	2	2	Diabetic Needs																						Diabetic Needs	0.00	0.00								0.00			0.00								0.00
H2663	009	0	1	01	01	H2663_009_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2663	010	0	1	01	01	H2663_010_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	010	0	1	01	01	H2663_010_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	78.00								39.00			78.00								39.00
H2663	010	0	1	01	01	H2663_010_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H2663	010	0	1	01	01	H2663_010_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	010	0	1	01	01	H2663_010_0	7	5	4	3	High Cholesterol Needs	001001	3	2	1		1	High Cholesterol Needs	111000000010010000000	30	90								30										90	31	High Cholesterol Needs	2	2	High Cholesterol Needs																						High Cholesterol Needs	0.00	0.00								0.00			0.00								0.00
H2663	010	0	1	01	01	H2663_010_0	7	1	4	3	Preferred Generic	001000	3	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H2663	010	0	1	01	01	H2663_010_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2663	010	0	1	01	01	H2663_010_0	7	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H2663	010	0	1	01	01	H2663_010_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2663	010	0	1	01	01	H2663_010_0	7	5	4	1	High Cholesterol Needs	001001	3	2				High Cholesterol Needs	111000000010010000000	30	90								30										90	31	High Cholesterol Needs	2	2	High Cholesterol Needs																						High Cholesterol Needs	0.00	0.00								0.00			0.00								0.00
H2663	011	0	1	01	01	H2663_011_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H2663	011	0	1	01	01	H2663_011_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	78.00								39.00			78.00								39.00
H2663	011	0	1	01	01	H2663_011_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H2663	011	0	1	01	01	H2663_011_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2663	011	0	1	01	01	H2663_011_0	6	5	4	3	High Cholesterol Needs	001001	3	2	1		1	High Cholesterol Needs	111000000010010000000	30	90								30										90	31	High Cholesterol Needs	2	2	High Cholesterol Needs																						High Cholesterol Needs	0.00	0.00								0.00			0.00								0.00
H2663	011	0	1	01	01	H2663_011_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2663	011	0	1	01	01	H2663_011_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H2663	011	0	1	01	01	H2663_011_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2663	011	0	1	01	01	H2663_011_0	6	1	4	3	Preferred Generic	001000	3	2	2			Preferred Generic																							Preferred Generic			Preferred Generic																						Preferred Generic																					
H2663	011	0	1	01	01	H2663_011_0	6	5	4	1	High Cholesterol Needs	001001	3	2				High Cholesterol Needs	111000000010010000000	30	90								30										90	31	High Cholesterol Needs	2	2	High Cholesterol Needs																						High Cholesterol Needs	0.00	0.00								0.00			0.00								0.00
H2663	012	0	1	01	01	H2663_012_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00											5.00
H2663	012	0	1	01	01	H2663_012_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00											32.00
H2663	012	0	1	01	01	H2663_012_0	8	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00											62.00
H2663	012	0	1	01	01	H2663_012_0	8	4	3	1	Specialty	010010		1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H2667	003	0	1	01	01	H2667_003_0	15	4	4	1	Tier 4	010010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H2667	003	0	1	01	01	H2667_003_0	15	3	4	1	Tier 3	100000	1	2				Tier 3	111100000010010000000	30	90	60							30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00			175.00								70.00
H2667	003	0	1	01	01	H2667_003_0	15	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010010000000	30	90	60							30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00
H2667	003	0	1	01	01	H2667_003_0	15	1	4	1	Tier 1	010000	1	2				Tier 1	111100000010010000000	30	90	60							30										90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00
H2672	001	0	1	01	01	H2672_001_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H2672	001	0	1	01	01	H2672_001_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H2672	001	0	1	01	01	H2672_001_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H2672	001	0	1	01	01	H2672_001_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	001	0	1	01	01	H2672_001_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H2672	001	0	1	01	01	H2672_001_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H2672	001	0	1	01	01	H2672_001_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H2672	001	0	1	01	01	H2672_001_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	003	0	1	01	01	H2672_003_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H2672	003	0	1	01	01	H2672_003_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H2672	003	0	1	01	01	H2672_003_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H2672	003	0	1	01	01	H2672_003_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	003	0	1	01	01	H2672_003_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H2672	003	0	1	01	01	H2672_003_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H2672	003	0	1	01	01	H2672_003_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H2672	003	0	1	01	01	H2672_003_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	008	0	1	01	01	H2672_008_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	008	0	1	01	01	H2672_008_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H2672	008	0	1	01	01	H2672_008_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H2672	008	0	1	01	01	H2672_008_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H2672	008	0	1	01	01	H2672_008_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H2672	008	0	1	01	01	H2672_008_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H2672	008	0	1	01	01	H2672_008_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H2672	008	0	1	01	01	H2672_008_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H2701	001	0	1	04	01	H2701_001_0	5	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	34	90								34		34								90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	30.00								10.00
H2701	001	0	1	04	01	H2701_001_0	5	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	34	90								34		34								90	34	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00
H2701	001	0	1	04	01	H2701_001_0	5	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H2701	001	0	1	04	01	H2701_001_0	5	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2701	001	0	1	04	01	H2701_001_0	5	1	4	3	Formulary Generic	010000	1	2	1		1	Formulary Generic	111000000010110000000	34	90								34		34								90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	30.00								10.00
H2701	001	0	1	04	01	H2701_001_0	5	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
H2701	001	0	1	04	01	H2701_001_0	5	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2701	001	0	1	04	01	H2701_001_0	5	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
H2701	003	0	1	04	01	H2701_003_0	6	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	34	90								34		34								90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	30.00								10.00
H2701	003	0	1	04	01	H2701_003_0	6	3	4	1	Formulary Brand	100000	1	2				Formulary Brand	111000000010110000000	34	90								34		34								90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	70.00	210.00								70.00		70.00	210.00								70.00
H2701	003	0	1	04	01	H2701_003_0	6	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	34	90								34		34								90	34	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H2701	003	0	1	04	01	H2701_003_0	6	4	4	1	Specialty	010011	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H2762	028	0	1	09	04	H2762_028_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	028	0	1	09	04	H2762_028_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	028	0	1	09	04	H2762_028_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	028	0	1	09	04	H2762_028_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	029	0	1	09	04	H2762_029_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	029	0	1	09	04	H2762_029_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	029	0	1	09	04	H2762_029_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	029	0	1	09	04	H2762_029_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	030	0	1	09	04	H2762_030_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	030	0	1	09	04	H2762_030_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	030	0	1	09	04	H2762_030_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	030	0	1	09	04	H2762_030_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	031	0	1	09	04	H2762_031_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	031	0	1	09	04	H2762_031_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	031	0	1	09	04	H2762_031_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	031	0	1	09	04	H2762_031_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	032	0	1	09	04	H2762_032_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	032	0	1	09	04	H2762_032_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	032	0	1	09	04	H2762_032_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	032	0	1	09	04	H2762_032_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	033	0	1	09	04	H2762_033_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	033	0	1	09	04	H2762_033_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	033	0	1	09	04	H2762_033_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	033	0	1	09	04	H2762_033_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	034	0	1	09	04	H2762_034_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	034	0	1	09	04	H2762_034_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	034	0	1	09	04	H2762_034_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	034	0	1	09	04	H2762_034_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	035	0	1	09	04	H2762_035_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	035	0	1	09	04	H2762_035_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	035	0	1	09	04	H2762_035_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	035	0	1	09	04	H2762_035_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	036	0	1	09	04	H2762_036_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	036	0	1	09	04	H2762_036_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	036	0	1	09	04	H2762_036_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	036	0	1	09	04	H2762_036_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	037	0	1	09	04	H2762_037_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	037	0	1	09	04	H2762_037_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	037	0	1	09	04	H2762_037_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	037	0	1	09	04	H2762_037_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	038	0	1	09	04	H2762_038_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	038	0	1	09	04	H2762_038_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	038	0	1	09	04	H2762_038_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	038	0	1	09	04	H2762_038_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	039	0	1	09	04	H2762_039_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	039	0	1	09	04	H2762_039_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	039	0	1	09	04	H2762_039_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	039	0	1	09	04	H2762_039_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	040	0	1	09	04	H2762_040_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	040	0	1	09	04	H2762_040_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	040	0	1	09	04	H2762_040_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	040	0	1	09	04	H2762_040_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	041	0	1	09	04	H2762_041_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	041	0	1	09	04	H2762_041_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	041	0	1	09	04	H2762_041_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	041	0	1	09	04	H2762_041_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	042	0	1	09	04	H2762_042_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	042	0	1	09	04	H2762_042_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	042	0	1	09	04	H2762_042_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	042	0	1	09	04	H2762_042_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	043	0	1	09	04	H2762_043_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	043	0	1	09	04	H2762_043_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	043	0	1	09	04	H2762_043_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	043	0	1	09	04	H2762_043_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	044	0	1	09	04	H2762_044_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	044	0	1	09	04	H2762_044_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	044	0	1	09	04	H2762_044_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	044	0	1	09	04	H2762_044_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	045	0	1	09	04	H2762_045_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	045	0	1	09	04	H2762_045_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	045	0	1	09	04	H2762_045_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	045	0	1	09	04	H2762_045_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	046	0	1	09	04	H2762_046_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	046	0	1	09	04	H2762_046_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	046	0	1	09	04	H2762_046_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	046	0	1	09	04	H2762_046_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	047	0	1	09	04	H2762_047_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	047	0	1	09	04	H2762_047_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	047	0	1	09	04	H2762_047_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	047	0	1	09	04	H2762_047_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	048	0	1	09	04	H2762_048_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	048	0	1	09	04	H2762_048_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	048	0	1	09	04	H2762_048_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	048	0	1	09	04	H2762_048_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	049	0	1	09	04	H2762_049_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	049	0	1	09	04	H2762_049_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	049	0	1	09	04	H2762_049_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	049	0	1	09	04	H2762_049_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	050	0	1	09	04	H2762_050_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	050	0	1	09	04	H2762_050_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	050	0	1	09	04	H2762_050_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	050	0	1	09	04	H2762_050_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	051	0	1	09	04	H2762_051_0	4	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	051	0	1	09	04	H2762_051_0	4	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	051	0	1	09	04	H2762_051_0	4	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	051	0	1	09	04	H2762_051_0	4	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	052	0	1	09	04	H2762_052_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	052	0	1	09	04	H2762_052_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	052	0	1	09	04	H2762_052_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	052	0	1	09	04	H2762_052_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	053	0	1	09	04	H2762_053_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2762	053	0	1	09	04	H2762_053_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	053	0	1	09	04	H2762_053_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	053	0	1	09	04	H2762_053_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	054	0	1	09	04	H2762_054_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	054	0	1	09	04	H2762_054_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	054	0	1	09	04	H2762_054_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00
H2762	054	0	1	09	04	H2762_054_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	055	0	1	09	04	H2762_055_0	3	2	3	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
H2762	055	0	1	09	04	H2762_055_0	3	4	3	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H2762	055	0	1	09	04	H2762_055_0	3	1	3	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00
H2762	055	0	1	09	04	H2762_055_0	3	3	3	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
H2775	004	0	1	04	01	H2775_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2775	004	0	1	04	01	H2775_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	004	0	1	04	01	H2775_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2775	004	0	1	04	01	H2775_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2775	004	0	1	04	01	H2775_004_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2775	004	0	1	04	01	H2775_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2775	004	0	1	04	01	H2775_004_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2775	004	0	1	04	01	H2775_004_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	005	0	1	04	01	H2775_005_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2775	005	0	1	04	01	H2775_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2775	005	0	1	04	01	H2775_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2775	005	0	1	04	01	H2775_005_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	005	0	1	04	01	H2775_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2775	005	0	1	04	01	H2775_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2775	005	0	1	04	01	H2775_005_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	005	0	1	04	01	H2775_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2775	006	0	1	04	01	H2775_006_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2775	006	0	1	04	01	H2775_006_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2775	006	0	1	04	01	H2775_006_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	006	0	1	04	01	H2775_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2775	006	0	1	04	01	H2775_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2775	006	0	1	04	01	H2775_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2775	006	0	1	04	01	H2775_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2775	006	0	1	04	01	H2775_006_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2802	001	0	1	01	01	H2802_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H2802	001	0	1	01	01	H2802_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H2802	001	0	1	01	01	H2802_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H2802	001	0	1	01	01	H2802_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2802	005	0	1	01	01	H2802_005_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2802	005	0	1	01	01	H2802_005_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2802	005	0	1	01	01	H2802_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2802	005	0	1	01	01	H2802_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	001	0	1	02	01	H2803_001_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H2803	001	0	1	02	01	H2803_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2803	001	0	1	02	01	H2803_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H2803	001	0	1	02	01	H2803_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	002	0	1	02	01	H2803_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2803	002	0	1	02	01	H2803_002_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H2803	002	0	1	02	01	H2803_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H2803	002	0	1	02	01	H2803_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	011	0	1	02	01	H2803_011_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2803	011	0	1	02	01	H2803_011_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H2803	011	0	1	02	01	H2803_011_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	011	0	1	02	01	H2803_011_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H2803	014	0	1	02	01	H2803_014_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2803	014	0	1	02	01	H2803_014_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2803	014	0	1	02	01	H2803_014_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2803	014	0	1	02	01	H2803_014_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	015	0	1	02	01	H2803_015_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H2803	015	0	1	02	01	H2803_015_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H2803	015	0	1	02	01	H2803_015_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2803	015	0	1	02	01	H2803_015_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H2869	002	0	1	04	01	H2869_002_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2869	002	0	1	04	01	H2869_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2869	002	0	1	04	01	H2869_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2869	002	0	1	04	01	H2869_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2869	002	0	1	04	01	H2869_002_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2869	002	0	1	04	01	H2869_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2869	002	0	1	04	01	H2869_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2869	002	0	1	04	01	H2869_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2899	001	0	1	01	01	H2899_001_0	18	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2899	001	0	1	01	01	H2899_001_0	18	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H2899	001	0	1	01	01	H2899_001_0	18	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H2899	001	0	1	01	01	H2899_001_0	18	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H2899	001	0	1	01	01	H2899_001_0	18	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H2899	001	0	1	01	01	H2899_001_0	18	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H2899	001	0	1	01	01	H2899_001_0	18	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H2899	001	0	1	01	01	H2899_001_0	18	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	39.00	117.00								39.00						78.00			117.00		39.00
H2905	001	0	1	04	01	H2905_001_0	9	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00			20.00								9.00
H2905	001	0	1	04	01	H2905_001_0	9	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2905	001	0	1	04	01	H2905_001_0	9	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	35.00	105.00								35.00			90.00								35.00
H2906	003	0	1	04	01	H2906_003_0	7	4	4	1	Non- Preferred Brand Name	100000	1	2				Non- Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non- Preferred Brand Name	2	2	Non- Preferred Brand Name																						Non- Preferred Brand Name	70.00	175.00								70.00			175.00								70.00
H2906	003	0	1	04	01	H2906_003_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	100.00								40.00			100.00								40.00
H2906	003	0	1	04	01	H2906_003_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	4.00	10.00								4.00			10.00								4.00
H2906	003	0	1	04	01	H2906_003_0	7	5	4	1	Special Pharmaceutical	010010	1	1				Special Pharmaceutical	111000000010010000000	30	90								30										90	31	Special Pharmaceutical	2	1	Special Pharmaceutical	30	30								30			30								30	Special Pharmaceutical																					
H2906	003	0	1	04	01	H2906_003_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2914	003	0	1	04	01	H2914_003_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2914	003	0	1	04	01	H2914_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2914	003	0	1	04	01	H2914_003_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2914	003	0	1	04	01	H2914_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2914	003	0	1	04	01	H2914_003_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2914	003	0	1	04	01	H2914_003_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2914	003	0	1	04	01	H2914_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2914	003	0	1	04	01	H2914_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2914	004	0	1	04	01	H2914_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2914	004	0	1	04	01	H2914_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2914	004	0	1	04	01	H2914_004_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2914	004	0	1	04	01	H2914_004_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H2914	004	0	1	04	01	H2914_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H2914	004	0	1	04	01	H2914_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H2914	004	0	1	04	01	H2914_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H2914	004	0	1	04	01	H2914_004_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2931	002	0	1	02	01	H2931_002_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	002	0	1	02	01	H2931_002_0	8	3	4	1	Non-preferred	100100	1	2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2931	002	0	1	02	01	H2931_002_0	8	6	4	3	Special Coverage - Brand	000010	2	2	1		1	Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2931	002	0	1	02	01	H2931_002_0	8	5	4	3	Special Coverage - Generic	010000	2	2	1		1	Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2931	002	0	1	02	01	H2931_002_0	8	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	002	0	1	02	01	H2931_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	002	0	1	02	01	H2931_002_0	8	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2931	002	0	1	02	01	H2931_002_0	8	5	4	1	Special Coverage - Generic	010000	2	2				Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2931	002	0	1	02	01	H2931_002_0	8	6	4	1	Special Coverage - Brand	000010	2	2				Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2931	002	0	1	02	01	H2931_002_0	8	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	1		1	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2931	002	0	1	02	01	H2931_002_0	8	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	002	0	1	02	01	H2931_002_0	8	3	4	3	Non-preferred	100100	1	2	1		1	Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2931	004	0	1	01	01	H2931_004_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	47.00	141.00								47.00			100.00								47.00
H2931	004	0	1	01	01	H2931_004_0	8	1	3	1	Preferred Generic/Some Brand Maintenance	001001		2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00
H2931	004	0	1	01	01	H2931_004_0	8	3	3	1	Non-preferred	100100		2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	95.00									95.00											95.00
H2931	004	0	1	01	01	H2931_004_0	8	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	006	0	1	02	01	H2931_006_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	006	0	1	02	01	H2931_006_0	9	3	4	1	Non-preferred	100100	1	2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2931	006	0	1	02	01	H2931_006_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	006	0	1	02	01	H2931_006_0	9	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2931	006	0	1	02	01	H2931_006_0	9	5	4	1	Special Coverage - Generic	010000	2	2				Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2931	006	0	1	02	01	H2931_006_0	9	6	4	3	Special Coverage - Brand	000010	2	2	1		1	Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2931	006	0	1	02	01	H2931_006_0	9	5	4	3	Special Coverage - Generic	010000	2	2	1		1	Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2931	006	0	1	02	01	H2931_006_0	9	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	006	0	1	02	01	H2931_006_0	9	3	4	3	Non-preferred	100100	1	2	1		1	Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2931	006	0	1	02	01	H2931_006_0	9	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	006	0	1	02	01	H2931_006_0	9	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	1		1	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2931	006	0	1	02	01	H2931_006_0	9	6	4	1	Special Coverage - Brand	000010	2	2				Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2931	015	0	1	01	01	H2931_015_0	6	1	4	1	Preferred Generic/Some Brand Maintenance	001001	2	2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00
H2931	015	0	1	01	01	H2931_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	015	0	1	01	01	H2931_015_0	6	3	4	1	Non-preferred	100100	1	2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	55.00									55.00											55.00
H2931	015	0	1	01	01	H2931_015_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2931	015	0	1	01	01	H2931_015_0	6	5	4	1	Special Coverage - Vitamins	010010	2	2				Special Coverage - Vitamins	110000000010000000000	30									30											31	Special Coverage - Vitamins	2	2	Special Coverage - Vitamins																						Special Coverage - Vitamins	0.00									0.00											0.00
H2931	015	0	1	01	01	H2931_015_0	6	6	4	1	Special Coverage - Generic	010000	2	2				Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	10.00									10.00											10.00
H2931	015	0	1	01	01	H2931_015_0	6	7	4	3	Special Coverage - Brand	000010	2	2	2			Special Coverage - Brand																							Special Coverage - Brand			Special Coverage - Brand																						Special Coverage - Brand																					
H2931	015	0	1	01	01	H2931_015_0	6	5	4	3	Special Coverage - Vitamins	010010	2	2	2			Special Coverage - Vitamins																							Special Coverage - Vitamins			Special Coverage - Vitamins																						Special Coverage - Vitamins																					
H2931	015	0	1	01	01	H2931_015_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H2931	015	0	1	01	01	H2931_015_0	6	3	4	3	Non-preferred	100100	1	2	2			Non-preferred																							Non-preferred			Non-preferred																						Non-preferred																					
H2931	015	0	1	01	01	H2931_015_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2931	015	0	1	01	01	H2931_015_0	6	1	4	3	Preferred Generic/Some Brand Maintenance	001001	2	2	1		1	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00
H2931	015	0	1	01	01	H2931_015_0	6	7	4	1	Special Coverage - Brand	000010	2	2				Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2931	015	0	1	01	01	H2931_015_0	6	6	4	3	Special Coverage - Generic	010000	2	2	2			Special Coverage - Generic																							Special Coverage - Generic			Special Coverage - Generic																						Special Coverage - Generic																					
H2947	001	0	1	04	01	H2947_001_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H2947	001	0	1	04	01	H2947_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H2947	001	0	1	04	01	H2947_001_0	10	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H2947	001	0	1	04	01	H2947_001_0	10	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H2947	001	0	1	04	01	H2947_001_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2947	001	0	1	04	01	H2947_001_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H2947	001	0	1	04	01	H2947_001_0	10	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H2947	001	0	1	04	01	H2947_001_0	10	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H2947	002	0	1	04	01	H2947_002_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H2947	002	0	1	04	01	H2947_002_0	7	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H2947	002	0	1	04	01	H2947_002_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2947	002	0	1	04	01	H2947_002_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H2947	002	0	1	04	01	H2947_002_0	7	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H2947	002	0	1	04	01	H2947_002_0	7	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H2947	002	0	1	04	01	H2947_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H2947	002	0	1	04	01	H2947_002_0	7	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H2949	002	0	1	01	01	H2949_002_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	002	0	1	01	01	H2949_002_0	8	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	002	0	1	01	01	H2949_002_0	8	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	002	0	1	01	01	H2949_002_0	8	4	4	3	Speciality	100100	1	1	1	10001000	2	Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2949	002	0	1	01	01	H2949_002_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	002	0	1	01	01	H2949_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	002	0	1	01	01	H2949_002_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	002	0	1	01	01	H2949_002_0	8	4	4	1	Speciality	100100	1	1				Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2949	007	0	1	01	01	H2949_007_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	007	0	1	01	01	H2949_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	007	0	1	01	01	H2949_007_0	6	4	4	3	Speciality	100100	1	1	1	10001000	2	Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2949	007	0	1	01	01	H2949_007_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	007	0	1	01	01	H2949_007_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	007	0	1	01	01	H2949_007_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	007	0	1	01	01	H2949_007_0	6	4	4	1	Speciality	100100	1	1				Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2949	007	0	1	01	01	H2949_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	012	0	1	01	01	H2949_012_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	012	0	1	01	01	H2949_012_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	012	0	1	01	01	H2949_012_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	012	0	1	01	01	H2949_012_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H2949	012	0	1	01	01	H2949_012_0	6	4	4	1	Speciality	100100	1	1				Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2949	012	0	1	01	01	H2949_012_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H2949	012	0	1	01	01	H2949_012_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H2949	012	0	1	01	01	H2949_012_0	6	4	4	3	Speciality	100100	1	1	1	10001000	2	Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H2960	004	0	1	01	01	H2960_004_0	7	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2960	004	0	1	01	01	H2960_004_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00
H2960	004	0	1	01	01	H2960_004_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	100.00								40.00			100.00								40.00
H2960	004	0	1	01	01	H2960_004_0	7	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			175.00								70.00
H2960	004	0	1	01	01	H2960_004_0	7	5	4	1	Special Pharmaceutical	010010	1	1				Special Pharmaceutical	111000000010010000000	30	90								30										90	31	Special Pharmaceutical	2	1	Special Pharmaceutical	30	30								30			30								30	Special Pharmaceutical																					
H2960	004	0	1	01	01	H2960_004_0	7	5	4	3	Special Pharmaceutical	010010	1	1	2			Special Pharmaceutical																							Special Pharmaceutical			Special Pharmaceutical																						Special Pharmaceutical																					
H2960	004	0	1	01	01	H2960_004_0	7	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2960	004	0	1	01	01	H2960_004_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2960	004	0	1	01	01	H2960_004_0	7	2	4	3	Non-Preferred Generic	000100	3	2	1		1	Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00
H2960	004	0	1	01	01	H2960_004_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2960	010	0	1	01	01	H2960_010_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2960	010	0	1	01	01	H2960_010_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	4.00	10.00								4.00			10.00								4.00
H2960	010	0	1	01	01	H2960_010_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	100.00								40.00			100.00								40.00
H2960	010	0	1	01	01	H2960_010_0	7	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			175.00								70.00
H2960	010	0	1	01	01	H2960_010_0	7	5	4	1	Special Pharmaceutical	010010	1	1				Special Pharmaceutical	111000000010010000000	30	90								30										90	31	Special Pharmaceutical	2	1	Special Pharmaceutical	30	30								30			30								30	Special Pharmaceutical																					
H2960	012	0	1	01	01	H2960_012_0	7	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H2960	012	0	1	01	01	H2960_012_0	7	5	4	3	Special Pharmaceutical	010010	1	1	2			Special Pharmaceutical																							Special Pharmaceutical			Special Pharmaceutical																						Special Pharmaceutical																					
H2960	012	0	1	01	01	H2960_012_0	7	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H2960	012	0	1	01	01	H2960_012_0	7	2	4	3	Non-Preferred Generic	000100	3	2	1		1	Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00
H2960	012	0	1	01	01	H2960_012_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2960	012	0	1	01	01	H2960_012_0	7	5	4	1	Special Pharmaceutical	010010	1	1				Special Pharmaceutical	111000000010010000000	30	90								30										90	31	Special Pharmaceutical	2	1	Special Pharmaceutical	30	30								30			30								30	Special Pharmaceutical																					
H2960	012	0	1	01	01	H2960_012_0	7	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			175.00								70.00
H2960	012	0	1	01	01	H2960_012_0	7	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	100.00								40.00			100.00								40.00
H2960	012	0	1	01	01	H2960_012_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	111000000010010000000	30	90								30										90	31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00
H2960	012	0	1	01	01	H2960_012_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00
H2961	002	0	1	02	01	H2961_002_0	12	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2961	002	0	1	02	01	H2961_002_0	12	5	4	1	Special Coverage - Generic	010000	2	2				Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2961	002	0	1	02	01	H2961_002_0	12	6	4	1	Special Coverage - Brand	000010	2	2				Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2961	002	0	1	02	01	H2961_002_0	12	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	1		1	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2961	002	0	1	02	01	H2961_002_0	12	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2961	002	0	1	02	01	H2961_002_0	12	3	4	1	Non-preferred	100100	1	2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2961	002	0	1	02	01	H2961_002_0	12	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2961	002	0	1	02	01	H2961_002_0	12	5	4	3	Special Coverage - Generic	010000	2	2	1		1	Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2961	002	0	1	02	01	H2961_002_0	12	6	4	3	Special Coverage - Brand	000010	2	2	1		1	Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2961	002	0	1	02	01	H2961_002_0	12	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2961	002	0	1	02	01	H2961_002_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2961	002	0	1	02	01	H2961_002_0	12	3	4	3	Non-preferred	100100	1	2	1		1	Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2961	011	0	1	02	01	H2961_011_0	9	5	4	1	Special Coverage - Generic	010000	2	2				Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2961	011	0	1	02	01	H2961_011_0	9	6	4	1	Special Coverage - Brand	000010	2	2				Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2961	011	0	1	02	01	H2961_011_0	9	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	1		1	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2961	011	0	1	02	01	H2961_011_0	9	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2961	011	0	1	02	01	H2961_011_0	9	3	4	3	Non-preferred	100100	1	2	1		1	Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2961	011	0	1	02	01	H2961_011_0	9	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2961	011	0	1	02	01	H2961_011_0	9	5	4	3	Special Coverage - Generic	010000	2	2	1		1	Special Coverage - Generic	110000000010000000000	30									30											31	Special Coverage - Generic	2	2	Special Coverage - Generic																						Special Coverage - Generic	3.00									3.00											3.00
H2961	011	0	1	02	01	H2961_011_0	9	6	4	3	Special Coverage - Brand	000010	2	2	1		1	Special Coverage - Brand	110000000010000000000	30									30											31	Special Coverage - Brand	2	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00
H2961	011	0	1	02	01	H2961_011_0	9	3	4	1	Non-preferred	100100	1	2				Non-preferred	110000000010000000000	30									30											31	Non-preferred	2	2	Non-preferred																						Non-preferred	85.00									85.00											85.00
H2961	011	0	1	02	01	H2961_011_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H2961	011	0	1	02	01	H2961_011_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H2961	011	0	1	02	01	H2961_011_0	9	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2				Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30										90	31	Preferred Generic/Some Brand Maintenance	2	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	3.00	9.00								3.00			6.00								3.00
H2997	001	0	1	04	01	H2997_001_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H2997	001	0	1	04	01	H2997_001_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H2997	001	0	1	04	01	H2997_001_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H2997	001	0	1	04	01	H2997_001_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H2997	001	0	1	04	01	H2997_001_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H2997	001	0	1	04	01	H2997_001_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H2997	001	0	1	04	01	H2997_001_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H2997	001	0	1	04	01	H2997_001_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H2997	001	0	1	04	01	H2997_001_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H2997	001	0	1	04	01	H2997_001_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3011	001	0	1	09	04	H3011_001_0	5	4	4	1	Specialty Medication	110001	1	1				Specialty Medication	110000000010100000000	30									30		30									31	Specialty Medication	2	1	Specialty Medication	25									25		25									25	Specialty Medication																					
H3011	001	0	1	09	04	H3011_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H3011	001	0	1	09	04	H3011_001_0	5	2	4	1	Preferred Brands	000001	1	2				Preferred Brands	111000000010110000000	30	90								30		30								90	31	Preferred Brands	2	2	Preferred Brands																						Preferred Brands	35.00	105.00								35.00		35.00	70.00								35.00
H3011	001	0	1	09	04	H3011_001_0	5	1	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H3028	001	0	1	01	01	H3028_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H3028	001	0	1	01	01	H3028_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H3028	001	0	1	01	01	H3028_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H3028	001	0	1	01	01	H3028_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3028	001	0	1	01	01	H3028_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3028	001	0	1	01	01	H3028_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00
H3028	001	0	1	01	01	H3028_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H3028	001	0	1	01	01	H3028_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H3044	001	0	1	01	01	H3044_001_0	9	2	4	1	Brand	000011	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	39.00	117.00								39.00		39.00	78.00								39.00
H3044	001	0	1	01	01	H3044_001_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00								78.00		78.00	156.00								78.00
H3044	001	0	1	01	01	H3044_001_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	30	30								30		30	30								30	Specialty																					
H3044	001	0	1	01	01	H3044_001_0	9	1	4	1	Generics	011100	1	2				Generics	111000000010110000000	30	90								30		30								90	31	Generics	2	2	Generics																						Generics	8.00	24.00								8.00		8.00	16.00								8.00
H3044	003	0	1	01	01	H3044_003_0	9	1	4	3	Generics	011100	1	2	1		1	Generics	111000000010110000000	30	90								30		30								90	31	Generics	2	2	Generics																						Generics	8.00	24.00								8.00		8.00	16.00								8.00
H3044	003	0	1	01	01	H3044_003_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3044	003	0	1	01	01	H3044_003_0	9	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3044	003	0	1	01	01	H3044_003_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3044	003	0	1	01	01	H3044_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	120.00								60.00
H3044	003	0	1	01	01	H3044_003_0	9	2	4	1	Brand	000011	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00		30.00	60.00								30.00
H3044	003	0	1	01	01	H3044_003_0	9	1	4	1	Generics	011100	1	2				Generics	111000000010110000000	30	90								30		30								90	31	Generics	2	2	Generics																						Generics	8.00	24.00								8.00		8.00	16.00								8.00
H3044	003	0	1	01	01	H3044_003_0	9	2	4	3	Brand	000011	1	2	2			Brand																							Brand			Brand																						Brand																					
H3057	001	1	1	09	04	H3057_001_1	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	001	1	1	09	04	H3057_001_1	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H3057	001	1	1	09	04	H3057_001_1	4	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	001	1	1	09	04	H3057_001_1	4	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3057	001	1	1	09	04	H3057_001_1	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H3057	001	1	1	09	04	H3057_001_1	4	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3057	001	2	1	09	04	H3057_001_2	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	001	2	1	09	04	H3057_001_2	4	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	001	2	1	09	04	H3057_001_2	4	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3057	001	2	1	09	04	H3057_001_2	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H3057	001	2	1	09	04	H3057_001_2	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H3057	001	2	1	09	04	H3057_001_2	4	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3057	002	1	1	09	04	H3057_002_1	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H3057	002	1	1	09	04	H3057_002_1	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	002	1	1	09	04	H3057_002_1	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H3057	002	2	1	09	04	H3057_002_2	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H3057	002	2	1	09	04	H3057_002_2	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H3057	002	2	1	09	04	H3057_002_2	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	007	0	1	09	04	H3057_007_0	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	007	0	1	09	04	H3057_007_0	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		40.00	120.00	80.00							60.00
H3057	007	0	1	09	04	H3057_007_0	4	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3057	007	0	1	09	04	H3057_007_0	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00
H3057	007	0	1	09	04	H3057_007_0	4	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3057	007	0	1	09	04	H3057_007_0	4	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3057	008	0	1	09	04	H3057_008_0	4	2	4	1	Tier 2	000010	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		24.00	70.00	47.00							35.00
H3057	008	0	1	09	04	H3057_008_0	4	3	4	1	Tier 3	000010	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		44.00	130.00	87.00							65.00
H3057	008	0	1	09	04	H3057_008_0	4	1	4	1	Tier 1	010000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00
H3059	002	0	1	01	01	H3059_002_0	6	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			9.00								3.00
H3059	002	0	1	01	01	H3059_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H3059	002	0	1	01	01	H3059_002_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H3059	002	0	1	01	01	H3059_002_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H3107	004	0	1	02	01	H3107_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3107	004	0	1	02	01	H3107_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3107	004	0	1	02	01	H3107_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3107	004	0	1	02	01	H3107_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3107	005	0	1	02	01	H3107_005_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3107	005	0	1	02	01	H3107_005_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3107	005	0	1	02	01	H3107_005_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3107	005	0	1	02	01	H3107_005_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3113	001	0	1	01	01	H3113_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3113	001	0	1	01	01	H3113_001_0	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3113	001	0	1	01	01	H3113_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3113	001	0	1	01	01	H3113_001_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3113	002	0	1	01	01	H3113_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3113	002	0	1	01	01	H3113_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3113	002	0	1	01	01	H3113_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3113	002	0	1	01	01	H3113_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3152	022	0	1	01	01	H3152_022_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				13.00	32.50		13.00	39.00			13.00					26.00			39.00		13.00
H3152	022	0	1	01	01	H3152_022_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				3.00	7.50		3.00	9.00			3.00					6.00			9.00		3.00
H3152	022	0	1	01	01	H3152_022_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	022	0	1	01	01	H3152_022_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				65.00	162.50		65.00	195.00			65.00					130.00			195.00		65.00
H3152	022	0	1	01	01	H3152_022_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				24.00	60.00		24.00	72.00			24.00					48.00			72.00		24.00
H3152	046	0	1	01	01	H3152_046_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	046	0	1	01	01	H3152_046_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3152	046	0	1	01	01	H3152_046_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3152	046	0	1	01	01	H3152_046_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H3152	046	0	1	01	01	H3152_046_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H3152	047	0	1	01	01	H3152_047_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
H3152	047	0	1	01	01	H3152_047_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	047	0	1	01	01	H3152_047_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				70.00	175.00		70.00	210.00			70.00					140.00			210.00		70.00
H3152	047	0	1	01	01	H3152_047_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3152	047	0	1	01	01	H3152_047_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3152	048	0	1	01	01	H3152_048_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3152	048	0	1	01	01	H3152_048_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3152	048	0	1	01	01	H3152_048_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3152	048	0	1	01	01	H3152_048_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H3152	048	0	1	01	01	H3152_048_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3152	048	0	1	01	01	H3152_048_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3152	048	0	1	01	01	H3152_048_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3152	048	0	1	01	01	H3152_048_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H3152	048	0	1	01	01	H3152_048_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H3152	048	0	1	01	01	H3152_048_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H3152	053	0	1	01	01	H3152_053_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H3152	053	0	1	01	01	H3152_053_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	053	0	1	01	01	H3152_053_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H3152	053	0	1	01	01	H3152_053_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3152	053	0	1	01	01	H3152_053_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3152	073	0	1	01	01	H3152_073_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H3152	073	0	1	01	01	H3152_073_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	073	0	1	01	01	H3152_073_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3152	073	0	1	01	01	H3152_073_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				14.00	35.00		14.00	42.00			14.00					28.00			42.00		14.00
H3152	073	0	1	01	01	H3152_073_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3152	074	0	1	01	01	H3152_074_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3152	074	0	1	01	01	H3152_074_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3152	074	0	1	01	01	H3152_074_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H3152	074	0	1	01	01	H3152_074_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				14.00	35.00		14.00	42.00			14.00					28.00			42.00		14.00
H3152	074	0	1	01	01	H3152_074_0	6	1	3	1	Tier1 - Preferred Generic	001000		2				Tier1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier1 - Preferred Generic	2	2	Tier1 - Preferred Generic																						Tier1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3154	004	0	1	01	01	H3154_004_0	6	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	004	0	1	01	01	H3154_004_0	6	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	004	0	1	01	01	H3154_004_0	6	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			21.00								7.00
H3154	004	0	1	01	01	H3154_004_0	6	4	2	1	Specialty	000010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3154	006	0	1	02	01	H3154_006_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	006	0	1	02	01	H3154_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	006	0	1	02	01	H3154_006_0	7	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H3154	006	0	1	02	01	H3154_006_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3154	006	0	1	02	01	H3154_006_0	7	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3154	006	0	1	02	01	H3154_006_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3154	006	0	1	02	01	H3154_006_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3154	006	0	1	02	01	H3154_006_0	7	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H3154	012	0	1	02	01	H3154_012_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	012	0	1	02	01	H3154_012_0	3	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			21.00								7.00
H3154	012	0	1	02	01	H3154_012_0	3	4	2	1	Specialty	000010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3154	012	0	1	02	01	H3154_012_0	3	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	015	0	1	02	01	H3154_015_0	7	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3154	015	0	1	02	01	H3154_015_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	015	0	1	02	01	H3154_015_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	015	0	1	02	01	H3154_015_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3154	015	0	1	02	01	H3154_015_0	7	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3154	015	0	1	02	01	H3154_015_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3154	015	0	1	02	01	H3154_015_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3154	015	0	1	02	01	H3154_015_0	7	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3154	016	0	1	01	01	H3154_016_0	4	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H3154	016	0	1	01	01	H3154_016_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	016	0	1	01	01	H3154_016_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	016	0	1	01	01	H3154_016_0	4	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3154	016	0	1	01	01	H3154_016_0	4	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H3154	016	0	1	01	01	H3154_016_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3154	016	0	1	01	01	H3154_016_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3154	016	0	1	01	01	H3154_016_0	4	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3154	017	0	1	01	01	H3154_017_0	8	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3154	017	0	1	01	01	H3154_017_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H3154	017	0	1	01	01	H3154_017_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
H3154	017	0	1	01	01	H3154_017_0	8	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3154	017	0	1	01	01	H3154_017_0	8	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3154	017	0	1	01	01	H3154_017_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3154	017	0	1	01	01	H3154_017_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3154	017	0	1	01	01	H3154_017_0	8	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3156	021	0	1	02	01	H3156_021_0	3	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3156	021	0	1	02	01	H3156_021_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H3156	021	0	1	02	01	H3156_021_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H3156	021	0	1	02	01	H3156_021_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H3156	026	0	1	01	01	H3156_026_0	3	4	3	1	Specialty	110001		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3156	026	0	1	01	01	H3156_026_0	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	186.00								62.00			124.00								62.00
H3156	026	0	1	01	01	H3156_026_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H3156	026	0	1	01	01	H3156_026_0	3	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H3156	028	0	1	01	01	H3156_028_0	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H3156	028	0	1	01	01	H3156_028_0	3	4	3	1	Specialty	110001		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3156	028	0	1	01	01	H3156_028_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H3156	028	0	1	01	01	H3156_028_0	3	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H3195	001	0	1	04	01	H3195_001_0	7	4	4	1	Specialty-Tier 4	010010	1	1				Specialty-Tier 4	111000000001110000000	31	90									10	31								90	31	Specialty-Tier 4	2	1	Specialty-Tier 4	33	33									33	33	33								33	Specialty-Tier 4																					
H3195	001	0	1	04	01	H3195_001_0	7	3	4	1	Non-Preferred Brand-Tier 3	100000	1	2				Non-Preferred Brand-Tier 3	111000000001110000000	31	90									10	31								90	31	Non-Preferred Brand-Tier 3	2	2	Non-Preferred Brand-Tier 3																						Non-Preferred Brand-Tier 3	15.00	45.00									15.00	15.00	45.00								15.00
H3195	001	0	1	04	01	H3195_001_0	7	2	4	1	Preferred Brand-Tier 2	000001	1	2				Preferred Brand-Tier 2	111000000001110000000	31	90									10	31								90	31	Preferred Brand-Tier 2	2	2	Preferred Brand-Tier 2																						Preferred Brand-Tier 2	10.00	30.00									10.00	10.00	30.00								10.00
H3195	001	0	1	04	01	H3195_001_0	7	1	4	1	Generic-Tier 1	010000	1	2				Generic-Tier 1	111000000001110000000	31	90									10	31								90	31	Generic-Tier 1	2	2	Generic-Tier 1																						Generic-Tier 1	5.00	15.00									5.00	5.00	15.00								5.00
H3195	001	0	1	04	01	H3195_001_0	7	1	4	3	Generic-Tier 1	010000	1	2	1		1	Generic-Tier 1	111000000001110000000	31	90									10	31								90	31	Generic-Tier 1	2	2	Generic-Tier 1																						Generic-Tier 1	5.00	15.00									5.00	5.00	15.00								5.00
H3195	001	0	1	04	01	H3195_001_0	7	2	4	3	Preferred Brand-Tier 2	000001	1	2	2			Preferred Brand-Tier 2																							Preferred Brand-Tier 2			Preferred Brand-Tier 2																						Preferred Brand-Tier 2																					
H3195	001	0	1	04	01	H3195_001_0	7	3	4	3	Non-Preferred Brand-Tier 3	100000	1	2	2			Non-Preferred Brand-Tier 3																							Non-Preferred Brand-Tier 3			Non-Preferred Brand-Tier 3																						Non-Preferred Brand-Tier 3																					
H3195	001	0	1	04	01	H3195_001_0	7	4	4	3	Specialty-Tier 4	010010	1	1	2			Specialty-Tier 4																							Specialty-Tier 4			Specialty-Tier 4																						Specialty-Tier 4																					
H3204	001	0	1	01	01	H3204_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	55.00	165.00								55.00			165.00								55.00
H3204	001	0	1	01	01	H3204_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
H3204	001	0	1	01	01	H3204_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3204	001	0	1	01	01	H3204_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3204	007	0	1	01	01	H3204_007_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3204	007	0	1	01	01	H3204_007_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H3204	007	0	1	01	01	H3204_007_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3204	007	0	1	01	01	H3204_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3204	007	0	1	01	01	H3204_007_0	5	1	4	3	Preferred Generic	001000	1	2	1	00100000	2	Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3204	007	0	1	01	01	H3204_007_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	55.00	165.00								55.00			165.00								55.00
H3204	007	0	1	01	01	H3204_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
H3204	007	0	1	01	01	H3204_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3206	001	0	1	04	01	H3206_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	55.00	165.00								55.00			165.00								55.00
H3206	001	0	1	04	01	H3206_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
H3206	001	0	1	04	01	H3206_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3206	001	0	1	04	01	H3206_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3206	002	0	1	04	01	H3206_002_0	5	1	4	3	Preferred Generic	001000	1	2	1	00100000	2	Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3206	002	0	1	04	01	H3206_002_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3206	002	0	1	04	01	H3206_002_0	5	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H3206	002	0	1	04	01	H3206_002_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3206	002	0	1	04	01	H3206_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H3206	002	0	1	04	01	H3206_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
H3206	002	0	1	04	01	H3206_002_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	55.00	165.00								55.00			165.00								55.00
H3206	002	0	1	04	01	H3206_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3207	001	0	1	04	01	H3207_001_0	11	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	66.00	198.00								66.00			198.00								66.00
H3207	001	0	1	04	01	H3207_001_0	11	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	1	Specialty Drug	33	33								33											33	Specialty Drug																					
H3207	001	0	1	04	01	H3207_001_0	11	1	4	1	Preferred generic	001000	1	2				Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	5.00	15.00								5.00			15.00								5.00
H3207	001	0	1	04	01	H3207_001_0	11	2	4	1	Preferred Brand	000101	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00
H3207	002	0	1	04	01	H3207_002_0	11	1	4	1	Preferred generic	001000	1	2				Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	6.00	18.00								6.00			18.00								6.00
H3207	002	0	1	04	01	H3207_002_0	11	2	4	1	Preferred Brand	000101	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H3207	002	0	1	04	01	H3207_002_0	11	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	80.00	240.00								80.00			240.00								80.00
H3207	002	0	1	04	01	H3207_002_0	11	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	1	Specialty Drug	33	33								33											33	Specialty Drug																					
H3207	003	0	1	04	01	H3207_003_0	9	1	4	1	Preferred generic	001010	1	2				Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	6.00	18.00								6.00			18.00								6.00
H3207	003	0	1	04	01	H3207_003_0	9	2	4	1	Preferred brand	000101	1	2				Preferred brand	111000000010010000000	30	90								30										90	31	Preferred brand	2	2	Preferred brand																						Preferred brand	35.00	105.00								35.00			105.00								35.00
H3207	003	0	1	04	01	H3207_003_0	9	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3207	003	0	1	04	01	H3207_003_0	9	4	4	3	Specialty Drug	111111	1	1	2			Specialty Drug																							Specialty Drug			Specialty Drug																						Specialty Drug																					
H3207	003	0	1	04	01	H3207_003_0	9	2	4	3	Preferred brand	000101	1	2	2			Preferred brand																							Preferred brand			Preferred brand																						Preferred brand																					
H3207	003	0	1	04	01	H3207_003_0	9	1	4	3	Preferred generic	001010	1	2	1		1	Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	6.00	18.00								6.00			18.00								6.00
H3207	003	0	1	04	01	H3207_003_0	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	75.00	225.00								75.00			225.00								75.00
H3207	003	0	1	04	01	H3207_003_0	9	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	1	Specialty Drug	25	25								25											25	Specialty Drug																					
H3207	004	0	1	04	01	H3207_004_0	10	1	4	3	Preferred generic	001010	1	2	1		1	Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	5.00	15.00								5.00			15.00								5.00
H3207	004	0	1	04	01	H3207_004_0	10	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	1	Specialty Drug	25	25								25											25	Specialty Drug																					
H3207	004	0	1	04	01	H3207_004_0	10	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	75.00	225.00								75.00			225.00								75.00
H3207	004	0	1	04	01	H3207_004_0	10	2	4	1	Preferred brand	000101	1	2				Preferred brand	111000000010010000000	30	90								30										90	31	Preferred brand	2	2	Preferred brand																						Preferred brand	35.00	105.00								35.00			105.00								35.00
H3207	004	0	1	04	01	H3207_004_0	10	1	4	1	Preferred generic	001010	1	2				Preferred generic	111000000010010000000	30	90								30										90	31	Preferred generic	2	2	Preferred generic																						Preferred generic	5.00	15.00								5.00			15.00								5.00
H3207	004	0	1	04	01	H3207_004_0	10	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3207	004	0	1	04	01	H3207_004_0	10	2	4	3	Preferred brand	000101	1	2	2			Preferred brand																							Preferred brand			Preferred brand																						Preferred brand																					
H3207	004	0	1	04	01	H3207_004_0	10	4	4	3	Specialty Drug	111111	1	1	2			Specialty Drug																							Specialty Drug			Specialty Drug																						Specialty Drug																					
H3208	001	0	1	04	01	H3208_001_0	10	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H3208	001	0	1	04	01	H3208_001_0	10	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				70.00	175.00		70.00	210.00		70.00			175.00								70.00
H3208	001	0	1	04	01	H3208_001_0	10	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00			17.50								7.00
H3208	001	0	1	04	01	H3208_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				40.00	100.00		40.00	120.00		40.00			100.00								40.00
H3208	003	0	1	04	01	H3208_003_0	7	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				10.00	25.00		10.00	30.00		10.00			25.00								10.00
H3208	003	0	1	04	01	H3208_003_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00
H3208	003	0	1	04	01	H3208_003_0	7	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				76.00	190.00		76.00	228.00		76.00			190.00								76.00
H3208	003	0	1	04	01	H3208_003_0	7	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H3208	004	0	1	04	01	H3208_004_0	10	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
H3208	004	0	1	04	01	H3208_004_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				38.00	95.00		38.00	114.00		38.00			95.00								38.00
H3208	004	0	1	04	01	H3208_004_0	10	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
H3208	004	0	1	04	01	H3208_004_0	10	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H3208	004	0	1	04	01	H3208_004_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
H3208	004	0	1	04	01	H3208_004_0	10	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H3208	004	0	1	04	01	H3208_004_0	10	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H3208	004	0	1	04	01	H3208_004_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3209	001	0	1	04	01	H3209_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3209	001	0	1	04	01	H3209_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3209	001	0	1	04	01	H3209_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3209	001	0	1	04	01	H3209_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3209	003	0	1	04	01	H3209_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3209	003	0	1	04	01	H3209_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3209	003	0	1	04	01	H3209_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3209	003	0	1	04	01	H3209_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3240	008	0	1	01	01	H3240_008_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	008	0	1	01	01	H3240_008_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H3240	008	0	1	01	01	H3240_008_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H3240	008	0	1	01	01	H3240_008_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H3240	008	0	1	01	01	H3240_008_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	008	0	1	01	01	H3240_008_0	5	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H3240	008	0	1	01	01	H3240_008_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3240	008	0	1	01	01	H3240_008_0	5	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H3240	009	0	1	01	01	H3240_009_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	009	0	1	01	01	H3240_009_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H3240	009	0	1	01	01	H3240_009_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H3240	009	0	1	01	01	H3240_009_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H3240	010	0	1	01	01	H3240_010_0	6	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	010	0	1	01	01	H3240_010_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H3240	010	0	1	01	01	H3240_010_0	6	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H3240	010	0	1	01	01	H3240_010_0	6	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H3240	010	0	1	01	01	H3240_010_0	6	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	010	0	1	01	01	H3240_010_0	6	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H3240	010	0	1	01	01	H3240_010_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3240	010	0	1	01	01	H3240_010_0	6	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H3240	013	0	1	01	01	H3240_013_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H3240	013	0	1	01	01	H3240_013_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H3240	013	0	1	01	01	H3240_013_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3240	013	0	1	01	01	H3240_013_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H3240	014	0	1	02	01	H3240_014_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H3240	014	0	1	02	01	H3240_014_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H3240	014	0	1	02	01	H3240_014_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	014	0	1	02	01	H3240_014_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H3240	014	0	1	02	01	H3240_014_0	3	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3240	014	0	1	02	01	H3240_014_0	3	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H3240	014	0	1	02	01	H3240_014_0	3	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H3240	014	0	1	02	01	H3240_014_0	3	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	015	0	1	02	01	H3240_015_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H3240	015	0	1	02	01	H3240_015_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H3240	015	0	1	02	01	H3240_015_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H3240	015	0	1	02	01	H3240_015_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H3251	002	0	1	01	01	H3251_002_0	8	1	4	1	Preferred Generic	001001	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00
H3251	002	0	1	01	01	H3251_002_0	8	2	4	1	Preferred Brand	000101	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			96.00								32.00
H3251	002	0	1	01	01	H3251_002_0	8	4	4	3	Specialty Drug	111111	1	1	2			Specialty Drug																							Specialty Drug			Specialty Drug																						Specialty Drug																					
H3251	002	0	1	01	01	H3251_002_0	8	3	4	3	Non Preferred	110100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3251	002	0	1	01	01	H3251_002_0	8	2	4	3	Preferred Brand	000101	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3251	002	0	1	01	01	H3251_002_0	8	1	4	3	Preferred Generic	001001	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00
H3251	002	0	1	01	01	H3251_002_0	8	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	4	Specialty Drug	25	25								25											25	Specialty Drug	250.00	750.00								250.00											250.00
H3251	002	0	1	01	01	H3251_002_0	8	3	4	1	Non Preferred	110100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	62.00	186.00								62.00			186.00								62.00
H3251	021	0	1	01	01	H3251_021_0	8	1	4	1	Preferred Generic	001001	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00
H3251	021	0	1	01	01	H3251_021_0	8	3	4	3	Non Preferred	110100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3251	021	0	1	01	01	H3251_021_0	8	2	4	3	Preferred Brand	000101	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3251	021	0	1	01	01	H3251_021_0	8	1	4	3	Preferred Generic	001001	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00
H3251	021	0	1	01	01	H3251_021_0	8	4	4	1	Specialty Drug	111111	1	1				Specialty Drug	111000000010000000000	30	90								30											31	Specialty Drug	2	4	Specialty Drug	25	25								25											25	Specialty Drug	250.00	750.00								250.00											250.00
H3251	021	0	1	01	01	H3251_021_0	8	3	4	1	Non Preferred	110100	1	2				Non Preferred	111000000010010000000	30	90								30										90	31	Non Preferred	2	2	Non Preferred																						Non Preferred	62.00	186.00								62.00			186.00								62.00
H3251	021	0	1	01	01	H3251_021_0	8	2	4	1	Preferred Brand	000101	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			96.00								32.00
H3251	021	0	1	01	01	H3251_021_0	8	4	4	3	Specialty Drug	111111	1	1	2			Specialty Drug																							Specialty Drug			Specialty Drug																						Specialty Drug																					
H3305	011	0	1	01	01	H3305_011_0	13	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H3305	011	0	1	01	01	H3305_011_0	13	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H3305	011	0	1	01	01	H3305_011_0	13	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H3307	002	0	1	01	01	H3307_002_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	002	0	1	01	01	H3307_002_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3307	002	0	1	01	01	H3307_002_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	002	0	1	01	01	H3307_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	011	0	1	01	01	H3307_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	011	0	1	01	01	H3307_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	011	0	1	01	01	H3307_011_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	011	0	1	01	01	H3307_011_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3307	012	0	1	01	01	H3307_012_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	012	0	1	01	01	H3307_012_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3307	012	0	1	01	01	H3307_012_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	012	0	1	01	01	H3307_012_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	013	0	1	01	01	H3307_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	013	0	1	01	01	H3307_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	013	0	1	01	01	H3307_013_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	013	0	1	01	01	H3307_013_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3307	015	0	1	01	01	H3307_015_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3307	015	0	1	01	01	H3307_015_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3307	015	0	1	01	01	H3307_015_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3307	015	0	1	01	01	H3307_015_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	015	0	1	01	01	H3307_015_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	015	0	1	01	01	H3307_015_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3307	015	0	1	01	01	H3307_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	015	0	1	01	01	H3307_015_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3307	021	0	1	01	01	H3307_021_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3307	021	0	1	01	01	H3307_021_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00						16.00			24.00		8.00
H3307	021	0	1	01	01	H3307_021_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3307	021	0	1	01	01	H3307_021_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3307	021	0	1	01	01	H3307_021_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3307	021	0	1	01	01	H3307_021_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3307	021	0	1	01	01	H3307_021_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00						16.00			24.00		8.00
H3307	021	0	1	01	01	H3307_021_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3312	002	0	1	01	01	H3312_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	002	0	1	01	01	H3312_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	002	0	1	01	01	H3312_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	002	0	1	01	01	H3312_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	002	0	1	01	01	H3312_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	002	0	1	01	01	H3312_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	002	0	1	01	01	H3312_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	002	0	1	01	01	H3312_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	002	0	1	01	01	H3312_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	002	0	1	01	01	H3312_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	018	0	1	01	01	H3312_018_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	018	0	1	01	01	H3312_018_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H3312	018	0	1	01	01	H3312_018_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3312	018	0	1	01	01	H3312_018_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H3312	018	0	1	01	01	H3312_018_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H3312	025	0	1	01	01	H3312_025_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H3312	025	0	1	01	01	H3312_025_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H3312	025	0	1	01	01	H3312_025_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	025	0	1	01	01	H3312_025_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3312	025	0	1	01	01	H3312_025_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3312	028	0	1	01	01	H3312_028_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	028	0	1	01	01	H3312_028_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	028	0	1	01	01	H3312_028_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	1		1	Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H3312	028	0	1	01	01	H3312_028_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1		1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	90.00	270.00									90.00					180.00			270.00		90.00
H3312	028	0	1	01	01	H3312_028_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	028	0	1	01	01	H3312_028_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H3312	028	0	1	01	01	H3312_028_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	1		1	Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	028	0	1	01	01	H3312_028_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	028	0	1	01	01	H3312_028_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	028	0	1	01	01	H3312_028_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
H3312	037	0	1	01	01	H3312_037_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	037	0	1	01	01	H3312_037_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	037	0	1	01	01	H3312_037_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	037	0	1	01	01	H3312_037_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	037	0	1	01	01	H3312_037_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	037	0	1	01	01	H3312_037_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	037	0	1	01	01	H3312_037_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	037	0	1	01	01	H3312_037_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	037	0	1	01	01	H3312_037_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	037	0	1	01	01	H3312_037_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	043	0	1	01	01	H3312_043_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H3312	043	0	1	01	01	H3312_043_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H3312	043	0	1	01	01	H3312_043_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	043	0	1	01	01	H3312_043_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3312	043	0	1	01	01	H3312_043_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3312	044	0	1	01	01	H3312_044_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	044	0	1	01	01	H3312_044_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	044	0	1	01	01	H3312_044_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	044	0	1	01	01	H3312_044_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	044	0	1	01	01	H3312_044_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	044	0	1	01	01	H3312_044_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	044	0	1	01	01	H3312_044_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	044	0	1	01	01	H3312_044_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	044	0	1	01	01	H3312_044_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	044	0	1	01	01	H3312_044_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	048	0	1	01	01	H3312_048_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H3312	048	0	1	01	01	H3312_048_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	048	0	1	01	01	H3312_048_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3312	048	0	1	01	01	H3312_048_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H3312	048	0	1	01	01	H3312_048_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3312	050	0	1	01	01	H3312_050_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	050	0	1	01	01	H3312_050_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	050	0	1	01	01	H3312_050_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	050	0	1	01	01	H3312_050_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	050	0	1	01	01	H3312_050_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	050	0	1	01	01	H3312_050_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	050	0	1	01	01	H3312_050_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	050	0	1	01	01	H3312_050_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	050	0	1	01	01	H3312_050_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	050	0	1	01	01	H3312_050_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	052	0	1	01	01	H3312_052_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	052	0	1	01	01	H3312_052_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	052	0	1	01	01	H3312_052_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	052	0	1	01	01	H3312_052_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	052	0	1	01	01	H3312_052_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	052	0	1	01	01	H3312_052_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	052	0	1	01	01	H3312_052_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	052	0	1	01	01	H3312_052_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	052	0	1	01	01	H3312_052_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	052	0	1	01	01	H3312_052_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	055	0	1	01	01	H3312_055_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	055	0	1	01	01	H3312_055_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	055	0	1	01	01	H3312_055_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
H3312	055	0	1	01	01	H3312_055_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H3312	055	0	1	01	01	H3312_055_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	1		1	Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	055	0	1	01	01	H3312_055_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	055	0	1	01	01	H3312_055_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3312	055	0	1	01	01	H3312_055_0	8	3	4	3	Tier 3 - Preferred Brand	000001	1	2	1		1	Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H3312	055	0	1	01	01	H3312_055_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1		1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	90.00	270.00									90.00					180.00			270.00		90.00
H3312	055	0	1	01	01	H3312_055_0	8	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3312	057	0	1	01	01	H3312_057_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H3312	057	0	1	01	01	H3312_057_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H3312	057	0	1	01	01	H3312_057_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H3312	057	0	1	01	01	H3312_057_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3312	057	0	1	01	01	H3312_057_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3312	058	0	1	01	01	H3312_058_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3312	058	0	1	01	01	H3312_058_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	058	0	1	01	01	H3312_058_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3312	058	0	1	01	01	H3312_058_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3312	058	0	1	01	01	H3312_058_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3312	058	0	1	01	01	H3312_058_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3312	058	0	1	01	01	H3312_058_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3312	058	0	1	01	01	H3312_058_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3312	058	0	1	01	01	H3312_058_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3312	058	0	1	01	01	H3312_058_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3327	001	0	1	01	01	H3327_001_0	15	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	001	0	1	01	01	H3327_001_0	15	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	001	0	1	01	01	H3327_001_0	15	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	001	0	1	01	01	H3327_001_0	15	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	001	0	1	01	01	H3327_001_0	15	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	001	0	1	01	01	H3327_001_0	15	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	001	0	1	01	01	H3327_001_0	15	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	001	0	1	01	01	H3327_001_0	15	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	002	0	1	01	01	H3327_002_0	17	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	002	0	1	01	01	H3327_002_0	17	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	002	0	1	01	01	H3327_002_0	17	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	002	0	1	01	01	H3327_002_0	17	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	002	0	1	01	01	H3327_002_0	17	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	002	0	1	01	01	H3327_002_0	17	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	002	0	1	01	01	H3327_002_0	17	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	002	0	1	01	01	H3327_002_0	17	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	003	0	1	02	01	H3327_003_0	15	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	003	0	1	02	01	H3327_003_0	15	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	003	0	1	02	01	H3327_003_0	15	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	003	0	1	02	01	H3327_003_0	15	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	003	0	1	02	01	H3327_003_0	15	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	003	0	1	02	01	H3327_003_0	15	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	003	0	1	02	01	H3327_003_0	15	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	003	0	1	02	01	H3327_003_0	15	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	021	0	1	01	01	H3327_021_0	15	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	021	0	1	01	01	H3327_021_0	15	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	021	0	1	01	01	H3327_021_0	15	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	021	0	1	01	01	H3327_021_0	15	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	021	0	1	01	01	H3327_021_0	15	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	021	0	1	01	01	H3327_021_0	15	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	021	0	1	01	01	H3327_021_0	15	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	021	0	1	01	01	H3327_021_0	15	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	023	0	1	02	01	H3327_023_0	14	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	023	0	1	02	01	H3327_023_0	14	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	023	0	1	02	01	H3327_023_0	14	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	023	0	1	02	01	H3327_023_0	14	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	023	0	1	02	01	H3327_023_0	14	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	023	0	1	02	01	H3327_023_0	14	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	023	0	1	02	01	H3327_023_0	14	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	023	0	1	02	01	H3327_023_0	14	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	026	0	1	01	01	H3327_026_0	13	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	026	0	1	01	01	H3327_026_0	13	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	026	0	1	01	01	H3327_026_0	13	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	026	0	1	01	01	H3327_026_0	13	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	026	0	1	01	01	H3327_026_0	13	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	026	0	1	01	01	H3327_026_0	13	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	026	0	1	01	01	H3327_026_0	13	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	026	0	1	01	01	H3327_026_0	13	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	027	0	1	01	01	H3327_027_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	027	0	1	01	01	H3327_027_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	027	0	1	01	01	H3327_027_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	027	0	1	01	01	H3327_027_0	9	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	027	0	1	01	01	H3327_027_0	9	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	027	0	1	01	01	H3327_027_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	027	0	1	01	01	H3327_027_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	027	0	1	01	01	H3327_027_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	028	0	1	01	01	H3327_028_0	15	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	028	0	1	01	01	H3327_028_0	15	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	028	0	1	01	01	H3327_028_0	15	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	028	0	1	01	01	H3327_028_0	15	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3327	028	0	1	01	01	H3327_028_0	15	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	028	0	1	01	01	H3327_028_0	15	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	028	0	1	01	01	H3327_028_0	15	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	028	0	1	01	01	H3327_028_0	15	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	029	0	1	01	01	H3327_029_0	13	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3327	029	0	1	01	01	H3327_029_0	13	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	029	0	1	01	01	H3327_029_0	13	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3327	029	0	1	01	01	H3327_029_0	13	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3327	029	0	1	01	01	H3327_029_0	13	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3327	029	0	1	01	01	H3327_029_0	13	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3327	029	0	1	01	01	H3327_029_0	13	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3327	029	0	1	01	01	H3327_029_0	13	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3328	002	0	1	01	01	H3328_002_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	46.50	139.50								46.50			139.50								46.50
H3328	002	0	1	01	01	H3328_002_0	8	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00								98.00			294.00								98.00
H3328	002	0	1	01	01	H3328_002_0	8	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3328	002	0	1	01	01	H3328_002_0	8	4	3	1	Specialty	000001		1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3328	003	0	1	02	01	H3328_003_0	14	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00
H3328	003	0	1	02	01	H3328_003_0	14	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00
H3328	003	0	1	02	01	H3328_003_0	14	4	3	1	Specialty	000001		1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	27	27								27			27								27	Specialty																					
H3328	003	0	1	02	01	H3328_003_0	14	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
H3328	012	0	1	02	01	H3328_012_0	13	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	1.00	3.00								1.00			2.00								1.00
H3328	012	0	1	02	01	H3328_012_0	13	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3328	012	0	1	02	01	H3328_012_0	13	4	4	3	Specialty	000001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3328	012	0	1	02	01	H3328_012_0	13	4	4	1	Specialty	000001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3328	012	0	1	02	01	H3328_012_0	13	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			150.00								75.00
H3328	012	0	1	02	01	H3328_012_0	13	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			90.00								45.00
H3328	012	0	1	02	01	H3328_012_0	13	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	1.00	3.00								1.00			2.00								1.00
H3328	012	0	1	02	01	H3328_012_0	13	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3328	013	0	1	01	01	H3328_013_0	9	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	46.50	139.50								46.50			139.50								46.50
H3328	013	0	1	01	01	H3328_013_0	9	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00								98.00			294.00								98.00
H3328	013	0	1	01	01	H3328_013_0	9	4	3	1	Specialty	000001		1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3328	013	0	1	01	01	H3328_013_0	9	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3328	014	0	1	02	01	H3328_014_0	10	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	2.00	6.00								2.00			4.00								2.00
H3328	014	0	1	02	01	H3328_014_0	10	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	46.00	138.00								46.00			92.00								46.00
H3328	014	0	1	02	01	H3328_014_0	10	4	3	1	Specialty	000001		1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3328	014	0	1	02	01	H3328_014_0	10	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00			170.00								85.00
H3330	021	1	1	01	01	H3330_021_1	6	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	021	1	1	01	01	H3330_021_1	6	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	021	1	1	01	01	H3330_021_1	6	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	1	1	01	01	H3330_021_1	6	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	021	1	1	01	01	H3330_021_1	6	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	1	1	01	01	H3330_021_1	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	021	1	1	01	01	H3330_021_1	6	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	021	1	1	01	01	H3330_021_1	6	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	021	2	1	01	01	H3330_021_2	7	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	021	2	1	01	01	H3330_021_2	7	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	021	2	1	01	01	H3330_021_2	7	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	2	1	01	01	H3330_021_2	7	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	021	2	1	01	01	H3330_021_2	7	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	021	2	1	01	01	H3330_021_2	7	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	021	2	1	01	01	H3330_021_2	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	021	2	1	01	01	H3330_021_2	7	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	3	1	01	01	H3330_021_3	6	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	3	1	01	01	H3330_021_3	6	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	021	3	1	01	01	H3330_021_3	6	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	021	3	1	01	01	H3330_021_3	6	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	021	3	1	01	01	H3330_021_3	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	021	3	1	01	01	H3330_021_3	6	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	021	3	1	01	01	H3330_021_3	6	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	021	3	1	01	01	H3330_021_3	6	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	023	1	1	01	01	H3330_023_1	4	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	023	1	1	01	01	H3330_023_1	4	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	023	1	1	01	01	H3330_023_1	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	023	1	1	01	01	H3330_023_1	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	023	1	1	01	01	H3330_023_1	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	023	1	1	01	01	H3330_023_1	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	023	1	1	01	01	H3330_023_1	4	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	023	1	1	01	01	H3330_023_1	4	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	023	2	1	01	01	H3330_023_2	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	023	2	1	01	01	H3330_023_2	5	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	023	2	1	01	01	H3330_023_2	5	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	023	2	1	01	01	H3330_023_2	5	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	023	2	1	01	01	H3330_023_2	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	023	2	1	01	01	H3330_023_2	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	023	2	1	01	01	H3330_023_2	5	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	023	2	1	01	01	H3330_023_2	5	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	023	3	1	01	01	H3330_023_3	4	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	023	3	1	01	01	H3330_023_3	4	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	023	3	1	01	01	H3330_023_3	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	023	3	1	01	01	H3330_023_3	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	023	3	1	01	01	H3330_023_3	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	023	3	1	01	01	H3330_023_3	4	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	023	3	1	01	01	H3330_023_3	4	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	023	3	1	01	01	H3330_023_3	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	029	0	1	01	01	H3330_029_0	7	1	2	1	Tier 1	001000		2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	029	0	1	01	01	H3330_029_0	7	2	2	1	Tier 2	000001		2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																					
H3330	029	0	1	01	01	H3330_029_0	7	3	2	1	Tier 3	100100		2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																					
H3330	029	0	1	01	01	H3330_029_0	7	4	2	1	Tier 4	010010		1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	030	1	1	01	01	H3330_030_1	8	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	1	1	01	01	H3330_030_1	8	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	030	1	1	01	01	H3330_030_1	8	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	030	1	1	01	01	H3330_030_1	8	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	030	1	1	01	01	H3330_030_1	8	5	4	1	Tier 5	001001	1	2				Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	1	1	01	01	H3330_030_1	8	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	1	1	01	01	H3330_030_1	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	030	1	1	01	01	H3330_030_1	8	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	030	1	1	01	01	H3330_030_1	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	030	1	1	01	01	H3330_030_1	8	5	4	3	Tier 5	001001	1	2	1		1	Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	2	1	01	01	H3330_030_2	9	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	2	1	01	01	H3330_030_2	9	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	030	2	1	01	01	H3330_030_2	9	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	030	2	1	01	01	H3330_030_2	9	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	030	2	1	01	01	H3330_030_2	9	5	4	3	Tier 5	001001	1	2	1		1	Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	2	1	01	01	H3330_030_2	9	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	2	1	01	01	H3330_030_2	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	030	2	1	01	01	H3330_030_2	9	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	030	2	1	01	01	H3330_030_2	9	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	030	2	1	01	01	H3330_030_2	9	5	4	1	Tier 5	001001	1	2				Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	3	1	01	01	H3330_030_3	8	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	3	1	01	01	H3330_030_3	8	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
H3330	030	3	1	01	01	H3330_030_3	8	5	4	3	Tier 5	001001	1	2	1		1	Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	3	1	01	01	H3330_030_3	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3330	030	3	1	01	01	H3330_030_3	8	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3330	030	3	1	01	01	H3330_030_3	8	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3330	030	3	1	01	01	H3330_030_3	8	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	030	3	1	01	01	H3330_030_3	8	5	4	1	Tier 5	001001	1	2				Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3330	030	3	1	01	01	H3330_030_3	8	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	030	3	1	01	01	H3330_030_3	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3330	031	1	1	01	01	H3330_031_1	6	1	2	1	Tier 1	001000		2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	031	1	1	01	01	H3330_031_1	6	3	2	1	Tier 3	100100		2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																					
H3330	031	1	1	01	01	H3330_031_1	6	2	2	1	Tier 2	000001		2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																					
H3330	031	1	1	01	01	H3330_031_1	6	4	2	1	Tier 4	010010		1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	031	2	1	01	01	H3330_031_2	8	1	2	1	Tier 1	001000		2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
H3330	031	2	1	01	01	H3330_031_2	8	2	2	1	Tier 2	000001		2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																					
H3330	031	2	1	01	01	H3330_031_2	8	4	2	1	Tier 4	010010		1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
H3330	031	2	1	01	01	H3330_031_2	8	3	2	1	Tier 3	100100		2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																					
H3333	049	0	1	09	04	H3333_049_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	049	0	1	09	04	H3333_049_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	049	0	1	09	04	H3333_049_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	049	0	1	09	04	H3333_049_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	049	0	1	09	04	H3333_049_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	049	0	1	09	04	H3333_049_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	049	0	1	09	04	H3333_049_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	049	0	1	09	04	H3333_049_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	050	0	1	09	04	H3333_050_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	050	0	1	09	04	H3333_050_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	050	0	1	09	04	H3333_050_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	050	0	1	09	04	H3333_050_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	050	0	1	09	04	H3333_050_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	050	0	1	09	04	H3333_050_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	050	0	1	09	04	H3333_050_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	050	0	1	09	04	H3333_050_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	051	0	1	09	04	H3333_051_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	051	0	1	09	04	H3333_051_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	051	0	1	09	04	H3333_051_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	051	0	1	09	04	H3333_051_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	051	0	1	09	04	H3333_051_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	051	0	1	09	04	H3333_051_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	051	0	1	09	04	H3333_051_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	051	0	1	09	04	H3333_051_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	052	0	1	09	04	H3333_052_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	052	0	1	09	04	H3333_052_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	052	0	1	09	04	H3333_052_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	052	0	1	09	04	H3333_052_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	052	0	1	09	04	H3333_052_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	052	0	1	09	04	H3333_052_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	052	0	1	09	04	H3333_052_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	052	0	1	09	04	H3333_052_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	053	0	1	09	04	H3333_053_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	053	0	1	09	04	H3333_053_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	053	0	1	09	04	H3333_053_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	053	0	1	09	04	H3333_053_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	053	0	1	09	04	H3333_053_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	053	0	1	09	04	H3333_053_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	053	0	1	09	04	H3333_053_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	053	0	1	09	04	H3333_053_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	054	0	1	09	04	H3333_054_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	054	0	1	09	04	H3333_054_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	054	0	1	09	04	H3333_054_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	054	0	1	09	04	H3333_054_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	054	0	1	09	04	H3333_054_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3333	054	0	1	09	04	H3333_054_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	054	0	1	09	04	H3333_054_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3333	054	0	1	09	04	H3333_054_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3333	055	0	1	09	04	H3333_055_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	055	0	1	09	04	H3333_055_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	055	0	1	09	04	H3333_055_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	055	0	1	09	04	H3333_055_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	056	0	1	09	04	H3333_056_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	056	0	1	09	04	H3333_056_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	056	0	1	09	04	H3333_056_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	056	0	1	09	04	H3333_056_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	057	0	1	09	04	H3333_057_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	057	0	1	09	04	H3333_057_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	057	0	1	09	04	H3333_057_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	057	0	1	09	04	H3333_057_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	058	0	1	09	04	H3333_058_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	058	0	1	09	04	H3333_058_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	058	0	1	09	04	H3333_058_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	058	0	1	09	04	H3333_058_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	059	0	1	09	04	H3333_059_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	059	0	1	09	04	H3333_059_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3333	059	0	1	09	04	H3333_059_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	059	0	1	09	04	H3333_059_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	060	0	1	09	04	H3333_060_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3333	060	0	1	09	04	H3333_060_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3333	060	0	1	09	04	H3333_060_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3333	060	0	1	09	04	H3333_060_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3335	002	0	1	04	01	H3335_002_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	002	0	1	04	01	H3335_002_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	002	0	1	04	01	H3335_002_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	002	0	1	04	01	H3335_002_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	005	0	1	04	01	H3335_005_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	005	0	1	04	01	H3335_005_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	005	0	1	04	01	H3335_005_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	005	0	1	04	01	H3335_005_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	005	0	1	04	01	H3335_005_0	7	4	4	3	Specialty	000010	3	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3335	005	0	1	04	01	H3335_005_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3335	005	0	1	04	01	H3335_005_0	7	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3335	005	0	1	04	01	H3335_005_0	7	1	4	3	Generics	010000	3	2	1		1	Generics	111000000010010000000	30	90								30										90	31	Generics	2	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	006	0	1	04	01	H3335_006_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	006	0	1	04	01	H3335_006_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	006	0	1	04	01	H3335_006_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	006	0	1	04	01	H3335_006_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	008	0	1	04	01	H3335_008_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	008	0	1	04	01	H3335_008_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	008	0	1	04	01	H3335_008_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	008	0	1	04	01	H3335_008_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	008	0	1	04	01	H3335_008_0	7	4	4	3	Specialty	000010	3	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3335	008	0	1	04	01	H3335_008_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3335	008	0	1	04	01	H3335_008_0	7	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3335	008	0	1	04	01	H3335_008_0	7	1	4	3	Generics	010000	3	2	1		1	Generics	111000000010010000000	30	90								30										90	31	Generics	2	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	009	0	1	04	01	H3335_009_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	009	0	1	04	01	H3335_009_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	009	0	1	04	01	H3335_009_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	009	0	1	04	01	H3335_009_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	014	0	1	04	01	H3335_014_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	014	0	1	04	01	H3335_014_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	014	0	1	04	01	H3335_014_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	014	0	1	04	01	H3335_014_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	014	0	1	04	01	H3335_014_0	7	4	4	3	Specialty	000010	3	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3335	014	0	1	04	01	H3335_014_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3335	014	0	1	04	01	H3335_014_0	7	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3335	014	0	1	04	01	H3335_014_0	7	1	4	3	Generics	010000	3	2	1		1	Generics	111000000010010000000	30	90								30										90	31	Generics	2	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	015	0	1	04	01	H3335_015_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	015	0	1	04	01	H3335_015_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	015	0	1	04	01	H3335_015_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	015	0	1	04	01	H3335_015_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	017	0	1	04	01	H3335_017_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	017	0	1	04	01	H3335_017_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	017	0	1	04	01	H3335_017_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	017	0	1	04	01	H3335_017_0	7	1	4	3	Generics	010000	3	2	1		1	Generics	111000000010010000000	30	90								30										90	31	Generics	2	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	017	0	1	04	01	H3335_017_0	7	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3335	017	0	1	04	01	H3335_017_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3335	017	0	1	04	01	H3335_017_0	7	4	4	3	Specialty	000010	3	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3335	017	0	1	04	01	H3335_017_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	018	0	1	04	01	H3335_018_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	018	0	1	04	01	H3335_018_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	018	0	1	04	01	H3335_018_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	018	0	1	04	01	H3335_018_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	020	0	1	04	01	H3335_020_0	7	4	4	3	Specialty	000010	3	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3335	020	0	1	04	01	H3335_020_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3335	020	0	1	04	01	H3335_020_0	7	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3335	020	0	1	04	01	H3335_020_0	7	1	4	3	Generics	010000	3	2	1		1	Generics	111000000010010000000	30	90								30										90	31	Generics	2	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	020	0	1	04	01	H3335_020_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	020	0	1	04	01	H3335_020_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	020	0	1	04	01	H3335_020_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	020	0	1	04	01	H3335_020_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	021	0	1	04	01	H3335_021_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	021	0	1	04	01	H3335_021_0	7	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	021	0	1	04	01	H3335_021_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	021	0	1	04	01	H3335_021_0	7	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3335	032	0	1	04	01	H3335_032_0	8	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	032	0	1	04	01	H3335_032_0	8	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	032	0	1	04	01	H3335_032_0	8	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	032	0	1	04	01	H3335_032_0	8	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	036	0	1	04	01	H3335_036_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	036	0	1	04	01	H3335_036_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	036	0	1	04	01	H3335_036_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	036	0	1	04	01	H3335_036_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	037	0	1	04	01	H3335_037_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	037	0	1	04	01	H3335_037_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	037	0	1	04	01	H3335_037_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	037	0	1	04	01	H3335_037_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	038	0	1	04	01	H3335_038_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	038	0	1	04	01	H3335_038_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	038	0	1	04	01	H3335_038_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	038	0	1	04	01	H3335_038_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	039	0	1	04	01	H3335_039_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	039	0	1	04	01	H3335_039_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	039	0	1	04	01	H3335_039_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	039	0	1	04	01	H3335_039_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	040	0	1	04	01	H3335_040_0	10	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	040	0	1	04	01	H3335_040_0	10	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	040	0	1	04	01	H3335_040_0	10	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	040	0	1	04	01	H3335_040_0	10	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	046	0	1	04	01	H3335_046_0	8	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	046	0	1	04	01	H3335_046_0	8	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	046	0	1	04	01	H3335_046_0	8	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	046	0	1	04	01	H3335_046_0	8	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	047	0	1	04	01	H3335_047_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	047	0	1	04	01	H3335_047_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	047	0	1	04	01	H3335_047_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	047	0	1	04	01	H3335_047_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	048	0	1	04	01	H3335_048_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	048	0	1	04	01	H3335_048_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	048	0	1	04	01	H3335_048_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	048	0	1	04	01	H3335_048_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	049	0	1	04	01	H3335_049_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3335	049	0	1	04	01	H3335_049_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	049	0	1	04	01	H3335_049_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	049	0	1	04	01	H3335_049_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	050	0	1	04	01	H3335_050_0	9	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3335	050	0	1	04	01	H3335_050_0	9	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3335	050	0	1	04	01	H3335_050_0	9	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3335	050	0	1	04	01	H3335_050_0	9	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3336	001	0	1	01	01	H3336_001_0	6	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			10.00								5.00
H3336	001	0	1	01	01	H3336_001_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00			70.00								35.00
H3336	001	0	1	01	01	H3336_001_0	6	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3336	001	0	1	01	01	H3336_001_0	6	4	4	1	Tier 4 - Specialty (Generic and Brand)	010010	1	1				Tier 4 - Specialty (Generic and Brand)	111000000010010000000	30	90								30										90	31	Tier 4 - Specialty (Generic and Brand)	2	1	Tier 4 - Specialty (Generic and Brand)	25	25								25			25								25	Tier 4 - Specialty (Generic and Brand)																					
H3337	001	0	1	01	01	H3337_001_0	7	1	4	1	Preferred Generics	001000	3	2				Preferred Generics	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3337	001	0	1	01	01	H3337_001_0	7	2	4	1	Generics	010000	3	2				Generics	111100000010111000000	31	92	62							31		31	62							92	31	Generics	2	2	Generics																						Generics	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	001	0	1	01	01	H3337_001_0	7	6	4	3	Specialty Drugs	100000	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3337	001	0	1	01	01	H3337_001_0	7	5	4	3	Brands	000010	1	2	2			Brands																							Brands			Brands																						Brands																					
H3337	001	0	1	01	01	H3337_001_0	7	4	4	3	Preferred Brands	000001	1	2	2			Preferred Brands																							Preferred Brands			Preferred Brands																						Preferred Brands																					
H3337	001	0	1	01	01	H3337_001_0	7	3	4	3	Liberty Choice Drugs	000010	3	2	1		1	Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Liberty Choice Drugs	2	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	001	0	1	01	01	H3337_001_0	7	2	4	3	Generics	010000	3	2	1		1	Generics	111100000010111000000	31	92	62							31		31	62							92	31	Generics	2	2	Generics																						Generics	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	001	0	1	01	01	H3337_001_0	7	1	4	3	Preferred Generics	001000	3	2	1		1	Preferred Generics	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3337	001	0	1	01	01	H3337_001_0	7	6	4	1	Specialty Drugs	100000	1	1				Specialty Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H3337	001	0	1	01	01	H3337_001_0	7	5	4	1	Brands	000010	1	2				Brands	111100000010111000000	31	92	62							31		31	62							92	31	Brands	2	2	Brands																						Brands	50.00	150.00	100.00							50.00		50.00	150.00	100.00							50.00
H3337	001	0	1	01	01	H3337_001_0	7	4	4	1	Preferred Brands	000001	1	2				Preferred Brands	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Brands	2	2	Preferred Brands																						Preferred Brands	25.00	75.00	50.00							25.00		25.00	75.00	50.00							25.00
H3337	001	0	1	01	01	H3337_001_0	7	3	4	1	Liberty Choice Drugs	000010	3	2				Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Liberty Choice Drugs	2	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	004	0	1	01	01	H3337_004_0	8	1	4	1	Preferred Generics	001000	3	2				Preferred Generics	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3337	004	0	1	01	01	H3337_004_0	8	5	4	3	Brands	000010	1	2	2			Brands																							Brands			Brands																						Brands																					
H3337	004	0	1	01	01	H3337_004_0	8	4	4	3	Preferred Brands	000001	1	2	2			Preferred Brands																							Preferred Brands			Preferred Brands																						Preferred Brands																					
H3337	004	0	1	01	01	H3337_004_0	8	3	4	3	Liberty Choice Drugs	000010	3	2	1		1	Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Liberty Choice Drugs	2	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	004	0	1	01	01	H3337_004_0	8	2	4	3	Generics	010000	3	2	1		1	Generics	111100000010111000000	31	92	62							31		31	62							92	31	Generics	2	2	Generics																						Generics	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	004	0	1	01	01	H3337_004_0	8	6	4	3	Specialty Drugs	100000	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3337	004	0	1	01	01	H3337_004_0	8	6	4	1	Specialty Drugs	100000	1	1				Specialty Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H3337	004	0	1	01	01	H3337_004_0	8	5	4	1	Brands	000010	1	2				Brands	111100000010111000000	31	92	62							31		31	62							92	31	Brands	2	2	Brands																						Brands	50.00	150.00	100.00							50.00		50.00	150.00	100.00							50.00
H3337	004	0	1	01	01	H3337_004_0	8	4	4	1	Preferred Brands	000001	1	2				Preferred Brands	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Brands	2	2	Preferred Brands																						Preferred Brands	25.00	75.00	50.00							25.00		25.00	75.00	50.00							25.00
H3337	004	0	1	01	01	H3337_004_0	8	3	4	1	Liberty Choice Drugs	000010	3	2				Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	62							92	31	Liberty Choice Drugs	2	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	004	0	1	01	01	H3337_004_0	8	2	4	1	Generics	010000	3	2				Generics	111100000010111000000	31	92	62							31		31	62							92	31	Generics	2	2	Generics																						Generics	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H3337	004	0	1	01	01	H3337_004_0	8	1	4	3	Preferred Generics	001000	3	2	1		1	Preferred Generics	111100000010111000000	31	92	62							31		31	62							92	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3342	001	0	1	04	01	H3342_001_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	001	0	1	04	01	H3342_001_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3342	001	0	1	04	01	H3342_001_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3342	001	0	1	04	01	H3342_001_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3342	001	0	1	04	01	H3342_001_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3342	001	0	1	04	01	H3342_001_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3342	001	0	1	04	01	H3342_001_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	001	0	1	04	01	H3342_001_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3342	001	0	1	04	01	H3342_001_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3342	001	0	1	04	01	H3342_001_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3342	002	0	1	04	01	H3342_002_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	002	0	1	04	01	H3342_002_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3342	002	0	1	04	01	H3342_002_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3342	002	0	1	04	01	H3342_002_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3342	002	0	1	04	01	H3342_002_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3342	002	0	1	04	01	H3342_002_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3342	002	0	1	04	01	H3342_002_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3342	002	0	1	04	01	H3342_002_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3342	002	0	1	04	01	H3342_002_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3342	002	0	1	04	01	H3342_002_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	004	0	1	04	01	H3342_004_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3342	004	0	1	04	01	H3342_004_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	004	0	1	04	01	H3342_004_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3342	004	0	1	04	01	H3342_004_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3342	004	0	1	04	01	H3342_004_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3342	004	0	1	04	01	H3342_004_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3342	004	0	1	04	01	H3342_004_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	004	0	1	04	01	H3342_004_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3342	004	0	1	04	01	H3342_004_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3342	004	0	1	04	01	H3342_004_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3342	012	0	1	04	01	H3342_012_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	012	0	1	04	01	H3342_012_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3342	012	0	1	04	01	H3342_012_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3342	012	0	1	04	01	H3342_012_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3342	012	0	1	04	01	H3342_012_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3342	012	0	1	04	01	H3342_012_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3342	012	0	1	04	01	H3342_012_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3342	012	0	1	04	01	H3342_012_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3342	012	0	1	04	01	H3342_012_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3342	012	0	1	04	01	H3342_012_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3344	001	0	1	04	01	H3344_001_0	9	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00											60.00
H3344	001	0	1	04	01	H3344_001_0	9	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	33									33											33	Specialty Tier 4																					
H3344	001	0	1	04	01	H3344_001_0	9	1	4	3	Tier 1	001001	1	2	1	10001000	2	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3344	001	0	1	04	01	H3344_001_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3344	001	0	1	04	01	H3344_001_0	9	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3344	001	0	1	04	01	H3344_001_0	9	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3344	001	0	1	04	01	H3344_001_0	9	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3344	001	0	1	04	01	H3344_001_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3344	003	0	1	04	01	H3344_003_0	9	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	25									25											25	Specialty Tier 4																					
H3344	003	0	1	04	01	H3344_003_0	9	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3344	003	0	1	04	01	H3344_003_0	9	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3344	003	0	1	04	01	H3344_003_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3344	003	0	1	04	01	H3344_003_0	9	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H3344	003	0	1	04	01	H3344_003_0	9	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00											40.00
H3344	003	0	1	04	01	H3344_003_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			62.50								25.00
H3344	003	0	1	04	01	H3344_003_0	9	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H3346	002	0	1	04	01	H3346_002_0	14	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H3346	002	0	1	04	01	H3346_002_0	14	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H3346	002	0	1	04	01	H3346_002_0	14	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H3346	002	0	1	04	01	H3346_002_0	14	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H3346	002	0	1	04	01	H3346_002_0	14	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3346	002	0	1	04	01	H3346_002_0	14	3	4	3	Tier 3	010010	1	1	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3347	001	0	1	01	01	H3347_001_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3347	001	0	1	01	01	H3347_001_0	7	2	4	3	Preferred	000001	1	2	1		1	Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	001	0	1	01	01	H3347_001_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3347	001	0	1	01	01	H3347_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3347	001	0	1	01	01	H3347_001_0	7	3	4	1	Brand	100000	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H3347	001	0	1	01	01	H3347_001_0	7	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	001	0	1	01	01	H3347_001_0	7	3	4	3	Brand	100000	1	2	2			Brand																							Brand			Brand																						Brand																					
H3347	001	0	1	01	01	H3347_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3347	004	0	1	01	01	H3347_004_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	1.00	3.00								1.00			2.50								1.00
H3347	004	0	1	01	01	H3347_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3347	004	0	1	01	01	H3347_004_0	4	3	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H3347	004	0	1	01	01	H3347_004_0	4	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	005	0	1	01	01	H3347_005_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3347	005	0	1	01	01	H3347_005_0	6	3	4	3	Brand	100000	1	2	2			Brand																							Brand			Brand																						Brand																					
H3347	005	0	1	01	01	H3347_005_0	6	2	4	3	Preferred	000001	1	2	1		1	Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	005	0	1	01	01	H3347_005_0	6	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	005	0	1	01	01	H3347_005_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3347	005	0	1	01	01	H3347_005_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3347	005	0	1	01	01	H3347_005_0	6	3	4	1	Brand	100000	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H3347	005	0	1	01	01	H3347_005_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3347	006	0	1	01	01	H3347_006_0	8	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H3347	006	0	1	01	01	H3347_006_0	8	3	4	1	Brand	100000	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H3347	006	0	1	01	01	H3347_006_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3347	006	0	1	01	01	H3347_006_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3351	002	0	1	01	01	H3351_002_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3351	002	0	1	01	01	H3351_002_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	002	0	1	01	01	H3351_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	002	0	1	01	01	H3351_002_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	5.00	12.50								5.00			12.50								5.00
H3351	006	0	1	01	01	H3351_006_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	006	0	1	01	01	H3351_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	006	0	1	01	01	H3351_006_0	7	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3351	006	0	1	01	01	H3351_006_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3351	010	0	1	01	01	H3351_010_0	6	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3351	010	0	1	01	01	H3351_010_0	6	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	010	0	1	01	01	H3351_010_0	6	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3351	010	0	1	01	01	H3351_010_0	6	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	011	0	1	01	01	H3351_011_0	6	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	011	0	1	01	01	H3351_011_0	6	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	011	0	1	01	01	H3351_011_0	6	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3351	011	0	1	01	01	H3351_011_0	6	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3351	012	0	1	01	01	H3351_012_0	6	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3351	012	0	1	01	01	H3351_012_0	6	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	012	0	1	01	01	H3351_012_0	6	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3351	012	0	1	01	01	H3351_012_0	6	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	013	0	1	01	01	H3351_013_0	6	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3351	013	0	1	01	01	H3351_013_0	6	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3351	013	0	1	01	01	H3351_013_0	6	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3351	013	0	1	01	01	H3351_013_0	6	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3356	001	0	1	18	06	H3356_001_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
H3356	001	0	1	18	06	H3356_001_0	5	1	3	1	Generics	010000		2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
H3356	001	0	1	18	06	H3356_001_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
H3356	001	0	1	18	06	H3356_001_0	5	4	3	1	Specialty	000010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3359	001	0	1	01	01	H3359_001_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3359	001	0	1	01	01	H3359_001_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			100.00								40.00
H3359	001	0	1	01	01	H3359_001_0	7	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00								80.00			200.00								80.00
H3359	001	0	1	01	01	H3359_001_0	7	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3359	031	0	1	01	01	H3359_031_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H3359	031	0	1	01	01	H3359_031_0	7	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3359	031	0	1	01	01	H3359_031_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3359	031	0	1	01	01	H3359_031_0	7	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00
H3361	020	0	1	02	01	H3361_020_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	020	0	1	02	01	H3361_020_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	020	0	1	02	01	H3361_020_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	020	0	1	02	01	H3361_020_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	020	0	1	02	01	H3361_020_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	020	0	1	02	01	H3361_020_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	020	0	1	02	01	H3361_020_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	020	0	1	02	01	H3361_020_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	021	0	1	02	01	H3361_021_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	021	0	1	02	01	H3361_021_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	021	0	1	02	01	H3361_021_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	021	0	1	02	01	H3361_021_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	021	0	1	02	01	H3361_021_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	021	0	1	02	01	H3361_021_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	021	0	1	02	01	H3361_021_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	021	0	1	02	01	H3361_021_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	024	0	1	02	01	H3361_024_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	024	0	1	02	01	H3361_024_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	024	0	1	02	01	H3361_024_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	024	0	1	02	01	H3361_024_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	024	0	1	02	01	H3361_024_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	024	0	1	02	01	H3361_024_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	024	0	1	02	01	H3361_024_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	024	0	1	02	01	H3361_024_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	027	0	1	02	01	H3361_027_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00
H3361	027	0	1	02	01	H3361_027_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	027	0	1	02	01	H3361_027_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	027	0	1	02	01	H3361_027_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	031	0	1	01	01	H3361_031_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00
H3361	031	0	1	01	01	H3361_031_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	031	0	1	01	01	H3361_031_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H3361	031	0	1	01	01	H3361_031_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	043	0	1	02	01	H3361_043_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00
H3361	043	0	1	02	01	H3361_043_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	043	0	1	02	01	H3361_043_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	043	0	1	02	01	H3361_043_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	051	0	1	02	01	H3361_051_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	051	0	1	02	01	H3361_051_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	051	0	1	02	01	H3361_051_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	051	0	1	02	01	H3361_051_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	065	0	1	01	01	H3361_065_0	6	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	065	0	1	01	01	H3361_065_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00
H3361	065	0	1	01	01	H3361_065_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	065	0	1	01	01	H3361_065_0	6	3	3	1	tier 3	100000		2				tier 3	111000000010010000000	31	93								31										93	31	tier 3	2	2	tier 3																						tier 3	90.00	270.00								90.00			270.00								90.00
H3361	084	0	1	02	01	H3361_084_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00
H3361	084	0	1	02	01	H3361_084_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	084	0	1	02	01	H3361_084_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H3361	084	0	1	02	01	H3361_084_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	098	0	1	02	01	H3361_098_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	098	0	1	02	01	H3361_098_0	6	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H3361	098	0	1	02	01	H3361_098_0	6	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	098	0	1	02	01	H3361_098_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	099	0	1	02	01	H3361_099_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	099	0	1	02	01	H3361_099_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	099	0	1	02	01	H3361_099_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	099	0	1	02	01	H3361_099_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	099	0	1	02	01	H3361_099_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	099	0	1	02	01	H3361_099_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	099	0	1	02	01	H3361_099_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	099	0	1	02	01	H3361_099_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	102	0	1	02	01	H3361_102_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	102	0	1	02	01	H3361_102_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	102	0	1	02	01	H3361_102_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	102	0	1	02	01	H3361_102_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	104	0	1	02	01	H3361_104_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	104	0	1	02	01	H3361_104_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	104	0	1	02	01	H3361_104_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	104	0	1	02	01	H3361_104_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	104	0	1	02	01	H3361_104_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	104	0	1	02	01	H3361_104_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	104	0	1	02	01	H3361_104_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	104	0	1	02	01	H3361_104_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
H3361	105	0	1	01	01	H3361_105_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	105	0	1	01	01	H3361_105_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
H3361	105	0	1	01	01	H3361_105_0	7	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	105	0	1	01	01	H3361_105_0	7	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	106	0	1	02	01	H3361_106_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	106	0	1	02	01	H3361_106_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	106	0	1	02	01	H3361_106_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	106	0	1	02	01	H3361_106_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	106	0	1	02	01	H3361_106_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	106	0	1	02	01	H3361_106_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	106	0	1	02	01	H3361_106_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	106	0	1	02	01	H3361_106_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	107	0	1	02	01	H3361_107_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	107	0	1	02	01	H3361_107_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	107	0	1	02	01	H3361_107_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	107	0	1	02	01	H3361_107_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	107	0	1	02	01	H3361_107_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	107	0	1	02	01	H3361_107_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	107	0	1	02	01	H3361_107_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	107	0	1	02	01	H3361_107_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	109	0	1	01	01	H3361_109_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	109	0	1	01	01	H3361_109_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00
H3361	109	0	1	01	01	H3361_109_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00
H3361	109	0	1	01	01	H3361_109_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	110	0	1	01	01	H3361_110_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	110	0	1	01	01	H3361_110_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	110	0	1	01	01	H3361_110_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	89.00	267.00								89.00			267.00								89.00
H3361	110	0	1	01	01	H3361_110_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	111	0	1	01	01	H3361_111_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	111	0	1	01	01	H3361_111_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	111	0	1	01	01	H3361_111_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	111	0	1	01	01	H3361_111_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	111	0	1	01	01	H3361_111_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	111	0	1	01	01	H3361_111_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	111	0	1	01	01	H3361_111_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	111	0	1	01	01	H3361_111_0	9	1	4	3	Tier 1	010000	1	2	2			Tier 1																							Tier 1			Tier 1																						Tier 1																					
H3361	112	0	1	02	01	H3361_112_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	112	0	1	02	01	H3361_112_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	112	0	1	02	01	H3361_112_0	6	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3361	112	0	1	02	01	H3361_112_0	6	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	112	0	1	02	01	H3361_112_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	112	0	1	02	01	H3361_112_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H3361	112	0	1	02	01	H3361_112_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	112	0	1	02	01	H3361_112_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	113	0	1	02	01	H3361_113_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	113	0	1	02	01	H3361_113_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	113	0	1	02	01	H3361_113_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H3361	113	0	1	02	01	H3361_113_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	115	0	1	02	01	H3361_115_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00
H3361	115	0	1	02	01	H3361_115_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	115	0	1	02	01	H3361_115_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	115	0	1	02	01	H3361_115_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	116	0	1	01	01	H3361_116_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H3361	116	0	1	01	01	H3361_116_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	116	0	1	01	01	H3361_116_0	6	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00								83.00			249.00								83.00
H3361	116	0	1	01	01	H3361_116_0	6	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	117	0	1	02	01	H3361_117_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
H3361	117	0	1	02	01	H3361_117_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	117	0	1	02	01	H3361_117_0	6	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	87.00	261.00								87.00			261.00								87.00
H3361	117	0	1	02	01	H3361_117_0	6	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3361	125	0	1	02	01	H3361_125_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3361	125	0	1	02	01	H3361_125_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H3361	125	0	1	02	01	H3361_125_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H3361	125	0	1	02	01	H3361_125_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	125	0	1	02	01	H3361_125_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3361	125	0	1	02	01	H3361_125_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3361	125	0	1	02	01	H3361_125_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3361	125	0	1	02	01	H3361_125_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3362	003	0	1	01	01	H3362_003_0	8	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3362	003	0	1	01	01	H3362_003_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3362	003	0	1	01	01	H3362_003_0	8	1	4	3	Tier 1	001001	1	2	1	10001000	2	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3362	003	0	1	01	01	H3362_003_0	8	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	33									33											33	Specialty Tier 4																					
H3362	003	0	1	01	01	H3362_003_0	8	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00											60.00
H3362	003	0	1	01	01	H3362_003_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3362	003	0	1	01	01	H3362_003_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3362	003	0	1	01	01	H3362_003_0	8	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3362	004	0	1	01	01	H3362_004_0	7	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3362	004	0	1	01	01	H3362_004_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3362	004	0	1	01	01	H3362_004_0	7	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H3362	004	0	1	01	01	H3362_004_0	7	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	25									25											25	Specialty Tier 4																					
H3362	004	0	1	01	01	H3362_004_0	7	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00											40.00
H3362	004	0	1	01	01	H3362_004_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			62.50								25.00
H3362	004	0	1	01	01	H3362_004_0	7	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H3362	004	0	1	01	01	H3362_004_0	7	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3362	017	0	1	01	01	H3362_017_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H3362	017	0	1	01	01	H3362_017_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H3362	017	0	1	01	01	H3362_017_0	8	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3362	017	0	1	01	01	H3362_017_0	8	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3362	017	0	1	01	01	H3362_017_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3362	017	0	1	01	01	H3362_017_0	8	1	4	3	Tier 1	001001	1	2	1	10001000	2	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H3362	017	0	1	01	01	H3362_017_0	8	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	33									33											33	Specialty Tier 4																					
H3362	017	0	1	01	01	H3362_017_0	8	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00											70.00
H3362	020	0	1	01	01	H3362_020_0	8	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H3362	020	0	1	01	01	H3362_020_0	8	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3362	020	0	1	01	01	H3362_020_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3362	020	0	1	01	01	H3362_020_0	8	1	4	3	Tier 1	001001	1	2	1	10001000	2	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H3362	020	0	1	01	01	H3362_020_0	8	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	25									25											25	Specialty Tier 4																					
H3362	020	0	1	01	01	H3362_020_0	8	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00											50.00
H3362	020	0	1	01	01	H3362_020_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			62.50								25.00
H3362	020	0	1	01	01	H3362_020_0	8	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H3366	022	0	1	01	01	H3366_022_0	12	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3366	022	0	1	01	01	H3366_022_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3366	022	0	1	01	01	H3366_022_0	12	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00
H3366	022	0	1	01	01	H3366_022_0	12	4	4	3	Biological and Specialty Injectibles	100000	1	1	2			Biological and Specialty Injectibles																							Biological and Specialty Injectibles			Biological and Specialty Injectibles																						Biological and Specialty Injectibles																					
H3366	022	0	1	01	01	H3366_022_0	12	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3366	022	0	1	01	01	H3366_022_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3366	022	0	1	01	01	H3366_022_0	12	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3366	022	0	1	01	01	H3366_022_0	12	4	4	1	Biological and Specialty Injectibles	100000	1	1				Biological and Specialty Injectibles	111000000010010000000	30	90								30										90	31	Biological and Specialty Injectibles	2	1	Biological and Specialty Injectibles	25	25								25			25								25	Biological and Specialty Injectibles																					
H3370	001	0	1	01	01	H3370_001_0	11	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3370	001	0	1	01	01	H3370_001_0	11	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3370	001	0	1	01	01	H3370_001_0	11	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	001	0	1	01	01	H3370_001_0	11	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3370	001	0	1	01	01	H3370_001_0	11	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3370	001	0	1	01	01	H3370_001_0	11	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3370	001	0	1	01	01	H3370_001_0	11	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3370	001	0	1	01	01	H3370_001_0	11	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	001	0	1	01	01	H3370_001_0	11	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3370	001	0	1	01	01	H3370_001_0	11	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3370	002	0	1	01	01	H3370_002_0	13	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3370	002	0	1	01	01	H3370_002_0	13	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3370	002	0	1	01	01	H3370_002_0	13	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3370	002	0	1	01	01	H3370_002_0	13	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3370	002	0	1	01	01	H3370_002_0	13	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	002	0	1	01	01	H3370_002_0	13	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3370	002	0	1	01	01	H3370_002_0	13	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3370	002	0	1	01	01	H3370_002_0	13	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3370	002	0	1	01	01	H3370_002_0	13	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3370	002	0	1	01	01	H3370_002_0	13	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	003	0	1	01	01	H3370_003_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3370	003	0	1	01	01	H3370_003_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3370	003	0	1	01	01	H3370_003_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3370	003	0	1	01	01	H3370_003_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3370	003	0	1	01	01	H3370_003_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3370	003	0	1	01	01	H3370_003_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	003	0	1	01	01	H3370_003_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3370	003	0	1	01	01	H3370_003_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3370	003	0	1	01	01	H3370_003_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3370	003	0	1	01	01	H3370_003_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	004	0	1	01	01	H3370_004_0	5	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3370	004	0	1	01	01	H3370_004_0	5	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3370	004	0	1	01	01	H3370_004_0	5	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3370	004	0	1	01	01	H3370_004_0	5	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	004	0	1	01	01	H3370_004_0	5	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3370	004	0	1	01	01	H3370_004_0	5	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3370	004	0	1	01	01	H3370_004_0	5	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3370	004	0	1	01	01	H3370_004_0	5	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3370	004	0	1	01	01	H3370_004_0	5	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	004	0	1	01	01	H3370_004_0	5	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3370	014	0	1	01	01	H3370_014_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3370	014	0	1	01	01	H3370_014_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	014	0	1	01	01	H3370_014_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3370	014	0	1	01	01	H3370_014_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3370	014	0	1	01	01	H3370_014_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3370	014	0	1	01	01	H3370_014_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3370	014	0	1	01	01	H3370_014_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H3370	014	0	1	01	01	H3370_014_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3370	014	0	1	01	01	H3370_014_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H3370	014	0	1	01	01	H3370_014_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3379	001	0	1	01	01	H3379_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3379	001	0	1	01	01	H3379_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3379	001	0	1	01	01	H3379_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3379	001	0	1	01	01	H3379_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3379	002	0	1	01	01	H3379_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3379	002	0	1	01	01	H3379_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3379	002	0	1	01	01	H3379_002_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3379	002	0	1	01	01	H3379_002_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3379	005	0	1	01	01	H3379_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3379	005	0	1	01	01	H3379_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3379	005	0	1	01	01	H3379_005_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3379	005	0	1	01	01	H3379_005_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3379	007	0	1	01	01	H3379_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3379	007	0	1	01	01	H3379_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3379	007	0	1	01	01	H3379_007_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3379	007	0	1	01	01	H3379_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3379	022	0	1	01	01	H3379_022_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3379	022	0	1	01	01	H3379_022_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3379	022	0	1	01	01	H3379_022_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3379	022	0	1	01	01	H3379_022_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3384	013	0	1	01	01	H3384_013_0	8	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H3384	013	0	1	01	01	H3384_013_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H3384	013	0	1	01	01	H3384_013_0	8	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H3384	013	0	1	01	01	H3384_013_0	8	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H3384	019	0	1	01	01	H3384_019_0	7	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																					
H3384	019	0	1	01	01	H3384_019_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H3384	019	0	1	01	01	H3384_019_0	7	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.50	25.50								8.50		8.50	21.25								8.50
H3384	019	0	1	01	01	H3384_019_0	7	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H3384	040	0	1	01	01	H3384_040_0	5	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50
H3384	040	0	1	01	01	H3384_040_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H3384	040	0	1	01	01	H3384_040_0	5	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H3384	040	0	1	01	01	H3384_040_0	5	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	33	33								33		33	27								33	Specialty Injectables																					
H3384	040	0	1	01	01	H3384_040_0	5	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50
H3384	040	0	1	01	01	H3384_040_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H3384	040	0	1	01	01	H3384_040_0	5	3	4	3	Non-Preferred Brand/Generic	100100	1	2	2			Non-Preferred Brand/Generic																							Non-Preferred Brand/Generic			Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																					
H3384	040	0	1	01	01	H3384_040_0	5	4	4	3	Specialty Injectables	100001	1	1	2			Specialty Injectables																							Specialty Injectables			Specialty Injectables																						Specialty Injectables																					
H3384	041	0	1	01	01	H3384_041_0	7	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	55	55								55		55	45								55	Non-Preferred Brand/Generic																					
H3384	041	0	1	01	01	H3384_041_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H3384	041	0	1	01	01	H3384_041_0	7	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50
H3384	041	0	1	01	01	H3384_041_0	7	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H3384	041	0	1	01	01	H3384_041_0	7	4	4	3	Specialty Injectables	100001	1	1	2			Specialty Injectables																							Specialty Injectables			Specialty Injectables																						Specialty Injectables																					
H3384	041	0	1	01	01	H3384_041_0	7	3	4	3	Non-Preferred Brand/Generic	100100	1	2	2			Non-Preferred Brand/Generic																							Non-Preferred Brand/Generic			Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																					
H3384	041	0	1	01	01	H3384_041_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3384	041	0	1	01	01	H3384_041_0	7	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50
H3384	052	0	1	01	01	H3384_052_0	8	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	55	55								55		55	45								55	Non-Preferred Brand/Generic																					
H3384	052	0	1	01	01	H3384_052_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.50	127.50								42.50		42.50	106.25								42.50
H3384	052	0	1	01	01	H3384_052_0	8	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.50	25.50								8.50		8.50	21.25								8.50
H3384	052	0	1	01	01	H3384_052_0	8	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H3384	053	0	1	01	01	H3384_053_0	4	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H3384	053	0	1	01	01	H3384_053_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H3384	053	0	1	01	01	H3384_053_0	4	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H3384	053	0	1	01	01	H3384_053_0	4	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	33	33								33		33	27								33	Specialty Injectables																					
H3384	054	0	1	01	01	H3384_054_0	10	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	12.00								4.00
H3384	054	0	1	01	01	H3384_054_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H3384	054	0	1	01	01	H3384_054_0	10	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	2	Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic	45.00	135.00								45.00		45.00	112.50								45.00
H3384	054	0	1	01	01	H3384_054_0	10	3	4	3	Non-Preferred Brand/Generic	100100	1	2	2			Non-Preferred Brand/Generic																							Non-Preferred Brand/Generic			Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																					
H3384	054	0	1	01	01	H3384_054_0	10	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H3384	054	0	1	01	01	H3384_054_0	10	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00
H3384	054	0	1	01	01	H3384_054_0	10	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H3384	054	0	1	01	01	H3384_054_0	10	4	4	3	Specialty Injectables	100001	1	1	2			Specialty Injectables																							Specialty Injectables			Specialty Injectables																						Specialty Injectables																					
H3388	002	0	1	01	01	H3388_002_0	9	6	4	3	Tier 6 Formulary Specialty	010010	1	1	2			Tier 6 Formulary Specialty																							Tier 6 Formulary Specialty			Tier 6 Formulary Specialty																						Tier 6 Formulary Specialty																					
H3388	002	0	1	01	01	H3388_002_0	9	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H3388	002	0	1	01	01	H3388_002_0	9	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H3388	002	0	1	01	01	H3388_002_0	9	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3388	002	0	1	01	01	H3388_002_0	9	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3388	002	0	1	01	01	H3388_002_0	9	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H3388	002	0	1	01	01	H3388_002_0	9	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H3388	002	0	1	01	01	H3388_002_0	9	1	4	3	Tier 1 Formulary Value Generics	010000	1	2	1		1	Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H3388	002	0	1	01	01	H3388_002_0	9	2	4	3	Tier 2 Formulary Generics	010000	1	2	1		1	Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H3388	002	0	1	01	01	H3388_002_0	9	3	4	3	Tier 3 Formulary Preferred Brand	000001	1	2	2			Tier 3 Formulary Preferred Brand																							Tier 3 Formulary Preferred Brand			Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand																					
H3388	002	0	1	01	01	H3388_002_0	9	4	4	3	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2	2			Tier 4 Formulary Preferred Brand Diagnostic																							Tier 4 Formulary Preferred Brand Diagnostic			Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic																					
H3388	002	0	1	01	01	H3388_002_0	9	5	4	3	Tier 5 Formulary Non-Preferred Brand	100000	1	2	2			Tier 5 Formulary Non-Preferred Brand																							Tier 5 Formulary Non-Preferred Brand			Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand																					
H3388	004	0	1	01	01	H3388_004_0	8	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H3388	004	0	1	01	01	H3388_004_0	8	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3388	004	0	1	01	01	H3388_004_0	8	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3388	004	0	1	01	01	H3388_004_0	8	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H3388	004	0	1	01	01	H3388_004_0	8	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H3388	004	0	1	01	01	H3388_004_0	8	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H3388	010	0	1	01	01	H3388_010_0	6	1	4	3	Tier 1 Formulary Value Generics	010000	1	2	1		1	Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H3388	010	0	1	01	01	H3388_010_0	6	2	4	3	Tier 2 Formulary Generics	010000	1	2	1		1	Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H3388	010	0	1	01	01	H3388_010_0	6	3	4	3	Tier 3 Formulary Preferred Brand	000001	1	2	2			Tier 3 Formulary Preferred Brand																							Tier 3 Formulary Preferred Brand			Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand																					
H3388	010	0	1	01	01	H3388_010_0	6	4	4	3	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2	2			Tier 4 Formulary Preferred Brand Diagnostic																							Tier 4 Formulary Preferred Brand Diagnostic			Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic																					
H3388	010	0	1	01	01	H3388_010_0	6	5	4	3	Tier 5 Formulary Non-Preferred Brand	100000	1	2	2			Tier 5 Formulary Non-Preferred Brand																							Tier 5 Formulary Non-Preferred Brand			Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand																					
H3388	010	0	1	01	01	H3388_010_0	6	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H3388	010	0	1	01	01	H3388_010_0	6	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H3388	010	0	1	01	01	H3388_010_0	6	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3388	010	0	1	01	01	H3388_010_0	6	6	4	3	Tier 6 Formulary Specialty	010010	1	1	2			Tier 6 Formulary Specialty																							Tier 6 Formulary Specialty			Tier 6 Formulary Specialty																						Tier 6 Formulary Specialty																					
H3388	010	0	1	01	01	H3388_010_0	6	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H3388	010	0	1	01	01	H3388_010_0	6	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H3388	010	0	1	01	01	H3388_010_0	6	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H3404	001	0	1	04	01	H3404_001_0	4	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3404	001	0	1	04	01	H3404_001_0	4	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H3404	001	0	1	04	01	H3404_001_0	4	4	4	3	Tier 4 - Specialty	010010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H3404	001	0	1	04	01	H3404_001_0	4	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H3404	001	0	1	04	01	H3404_001_0	4	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3404	001	0	1	04	01	H3404_001_0	4	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3404	001	0	1	04	01	H3404_001_0	4	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
H3404	001	0	1	04	01	H3404_001_0	4	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	180.00	120.00							60.00
H3404	002	0	1	04	01	H3404_002_0	4	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3404	002	0	1	04	01	H3404_002_0	4	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H3404	002	0	1	04	01	H3404_002_0	4	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3404	002	0	1	04	01	H3404_002_0	4	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3404	002	0	1	04	01	H3404_002_0	4	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
H3404	002	0	1	04	01	H3404_002_0	4	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	180.00	120.00							60.00
H3404	002	0	1	04	01	H3404_002_0	4	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H3404	002	0	1	04	01	H3404_002_0	4	4	4	3	Tier 4 - Specialty	010010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H3405	001	0	1	04	01	H3405_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H3405	001	0	1	04	01	H3405_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H3405	001	0	1	04	01	H3405_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H3405	001	0	1	04	01	H3405_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3405	001	0	1	04	01	H3405_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H3405	001	0	1	04	01	H3405_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H3405	001	0	1	04	01	H3405_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H3405	001	0	1	04	01	H3405_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3405	002	0	1	04	01	H3405_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H3405	002	0	1	04	01	H3405_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H3405	002	0	1	04	01	H3405_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H3405	002	0	1	04	01	H3405_002_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3405	002	0	1	04	01	H3405_002_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H3405	002	0	1	04	01	H3405_002_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H3405	002	0	1	04	01	H3405_002_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H3405	002	0	1	04	01	H3405_002_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3415	001	0	1	04	01	H3415_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001010000000	31	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00									65.00		130.00								65.00
H3415	001	0	1	04	01	H3415_001_0	7	4	4	1	Specialty	100011	1	1				Specialty	110000000001000000000	31										10										31	Specialty	2	1	Specialty	25										25										25	Specialty																					
H3415	001	0	1	04	01	H3415_001_0	7	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	111000000001010000000	31	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00									40.00		80.00								40.00
H3415	001	0	1	04	01	H3415_001_0	7	1	4	1	Generic	011000	1	2				Generic	111000000001010000000	31	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		10.00								5.00
H3435	001	0	1	37	05	H3435_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3435	001	0	1	37	05	H3435_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3435	001	0	1	37	05	H3435_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3435	001	0	1	37	05	H3435_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H3435	003	0	1	37	05	H3435_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3435	003	0	1	37	05	H3435_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3435	003	0	1	37	05	H3435_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3435	003	0	1	37	05	H3435_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H3437	002	0	1	04	01	H3437_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3437	002	0	1	04	01	H3437_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H3437	002	0	1	04	01	H3437_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H3437	002	0	1	04	01	H3437_002_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3437	002	0	1	04	01	H3437_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H3437	002	0	1	04	01	H3437_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3437	002	0	1	04	01	H3437_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3437	002	0	1	04	01	H3437_002_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3449	005	0	1	01	01	H3449_005_0	5	4	4	3	Tier 4 - Specialty	010010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H3449	005	0	1	01	01	H3449_005_0	5	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H3449	005	0	1	01	01	H3449_005_0	5	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3449	005	0	1	01	01	H3449_005_0	5	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3449	005	0	1	01	01	H3449_005_0	5	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3449	005	0	1	01	01	H3449_005_0	5	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H3449	005	0	1	01	01	H3449_005_0	5	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	180.00	120.00							60.00
H3449	005	0	1	01	01	H3449_005_0	5	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
H3449	013	0	1	01	01	H3449_013_0	5	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
H3449	013	0	1	01	01	H3449_013_0	5	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00
H3449	013	0	1	01	01	H3449_013_0	5	3	4	1	Tier 3 - Non-preferred Brand	100000	1	2				Tier 3 - Non-preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-preferred Brand	2	2	Tier 3 - Non-preferred Brand																						Tier 3 - Non-preferred Brand	75.00	225.00	150.00							75.00		75.00	225.00	150.00							75.00
H3449	013	0	1	01	01	H3449_013_0	5	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
H3456	001	0	1	02	01	H3456_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3456	001	0	1	02	01	H3456_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H3456	001	0	1	02	01	H3456_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3456	001	0	1	02	01	H3456_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H3456	010	0	1	01	01	H3456_010_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3456	010	0	1	01	01	H3456_010_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3456	010	0	1	01	01	H3456_010_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3456	010	0	1	01	01	H3456_010_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3456	022	0	1	01	01	H3456_022_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3456	022	0	1	01	01	H3456_022_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3456	022	0	1	01	01	H3456_022_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3456	022	0	1	01	01	H3456_022_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3518	001	0	1	09	04	H3518_001_0	6	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H3518	001	0	1	09	04	H3518_001_0	6	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H3518	001	0	1	09	04	H3518_001_0	6	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H3518	001	0	1	09	04	H3518_001_0	6	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H3528	001	0	1	01	01	H3528_001_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3528	001	0	1	01	01	H3528_001_0	6	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3528	001	0	1	01	01	H3528_001_0	6	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3528	001	0	1	01	01	H3528_001_0	6	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	001	0	1	01	01	H3528_001_0	6	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																					
H3528	001	0	1	01	01	H3528_001_0	6	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3528	001	0	1	01	01	H3528_001_0	6	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	001	0	1	01	01	H3528_001_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	37.50	50.00	25.00	75.00	50.00	25.00		12.50	37.50	25.00							25.00
H3528	002	0	1	01	01	H3528_002_0	5	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3528	002	0	1	01	01	H3528_002_0	5	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3528	002	0	1	01	01	H3528_002_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3528	002	0	1	01	01	H3528_002_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	002	0	1	01	01	H3528_002_0	5	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																					
H3528	002	0	1	01	01	H3528_002_0	5	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3528	002	0	1	01	01	H3528_002_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	37.50	50.00	25.00	75.00	50.00	25.00		12.50	37.50	25.00							25.00
H3528	002	0	1	01	01	H3528_002_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	004	0	1	01	01	H3528_004_0	5	5	4	3	Tier 5	010010	1	2	1		1	Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3528	004	0	1	01	01	H3528_004_0	5	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3528	004	0	1	01	01	H3528_004_0	5	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3528	004	0	1	01	01	H3528_004_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3528	004	0	1	01	01	H3528_004_0	5	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3528	004	0	1	01	01	H3528_004_0	5	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																					
H3528	004	0	1	01	01	H3528_004_0	5	5	4	1	Tier 5	010010	1	2				Tier 5	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 5	2	2	Tier 5																						Tier 5				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0.00	0.00							0.00
H3528	004	0	1	01	01	H3528_004_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	004	0	1	01	01	H3528_004_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	004	0	1	01	01	H3528_004_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	37.50	50.00	25.00	75.00	50.00	25.00		12.50	37.50	25.00							25.00
H3528	005	0	1	01	01	H3528_005_0	5	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3528	005	0	1	01	01	H3528_005_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	005	0	1	01	01	H3528_005_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	37.50	50.00	25.00	75.00	50.00	25.00		12.50	37.50	25.00							25.00
H3528	005	0	1	01	01	H3528_005_0	5	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3528	005	0	1	01	01	H3528_005_0	5	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																					
H3528	005	0	1	01	01	H3528_005_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	005	0	1	01	01	H3528_005_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3528	005	0	1	01	01	H3528_005_0	5	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3528	006	0	1	02	01	H3528_006_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3528	006	0	1	02	01	H3528_006_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3528	006	0	1	02	01	H3528_006_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	37.50	50.00	25.00	75.00	50.00	25.00		12.50	37.50	25.00							25.00
H3528	006	0	1	02	01	H3528_006_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
H3528	006	0	1	02	01	H3528_006_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																					
H3528	006	0	1	02	01	H3528_006_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3528	006	0	1	02	01	H3528_006_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3528	006	0	1	02	01	H3528_006_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	7.50	10.00	5.00	15.00	10.00	5.00		2.50	7.50	5.00							5.00
H3533	001	0	1	01	01	H3533_001_0	9	4	4	3	Tier 4 - Specialty Drugs	000010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3533	001	0	1	01	01	H3533_001_0	9	3	4	3	Tier 3 - Non - Preferred Brand	100000	1	2	2			Tier 3 - Non - Preferred Brand																							Tier 3 - Non - Preferred Brand			Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand																					
H3533	001	0	1	01	01	H3533_001_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3533	001	0	1	01	01	H3533_001_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H3533	001	0	1	01	01	H3533_001_0	9	4	4	1	Tier 4 - Specialty Drugs	000010	1	1				Tier 4 - Specialty Drugs	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drugs	2	4	Tier 4 - Specialty Drugs	25	25								25						25			25		25	Tier 4 - Specialty Drugs	200.00	600.00								200.00						600.00			600.00		200.00
H3533	001	0	1	01	01	H3533_001_0	9	3	4	1	Tier 3 - Non - Preferred Brand	100000	1	2				Tier 3 - Non - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non - Preferred Brand	2	2	Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H3533	001	0	1	01	01	H3533_001_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H3533	001	0	1	01	01	H3533_001_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H3597	001	0	1	01	01	H3597_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3597	001	0	1	01	01	H3597_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3597	001	0	1	01	01	H3597_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3597	001	0	1	01	01	H3597_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3597	001	0	1	01	01	H3597_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3597	002	0	1	01	01	H3597_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3597	002	0	1	01	01	H3597_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H3597	002	0	1	01	01	H3597_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3597	002	0	1	01	01	H3597_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3597	002	0	1	01	01	H3597_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3597	002	0	1	01	01	H3597_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3597	002	0	1	01	01	H3597_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H3597	002	0	1	01	01	H3597_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H3597	002	0	1	01	01	H3597_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H3597	002	0	1	01	01	H3597_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3597	004	0	1	01	01	H3597_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3597	004	0	1	01	01	H3597_004_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3597	004	0	1	01	01	H3597_004_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
H3597	004	0	1	01	01	H3597_004_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H3597	004	0	1	01	01	H3597_004_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	1		1	Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3597	004	0	1	01	01	H3597_004_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3597	004	0	1	01	01	H3597_004_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3597	004	0	1	01	01	H3597_004_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	1		1	Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H3597	004	0	1	01	01	H3597_004_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1		1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	90.00	270.00									90.00					180.00			270.00		90.00
H3597	004	0	1	01	01	H3597_004_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3619	001	0	1	04	01	H3619_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3619	001	0	1	04	01	H3619_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	001	0	1	04	01	H3619_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	001	0	1	04	01	H3619_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	001	0	1	04	01	H3619_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3619	001	0	1	04	01	H3619_001_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	001	0	1	04	01	H3619_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	001	0	1	04	01	H3619_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	004	0	1	04	01	H3619_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	004	0	1	04	01	H3619_004_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3619	004	0	1	04	01	H3619_004_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	004	0	1	04	01	H3619_004_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	004	0	1	04	01	H3619_004_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	004	0	1	04	01	H3619_004_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3619	004	0	1	04	01	H3619_004_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	004	0	1	04	01	H3619_004_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	012	0	1	04	01	H3619_012_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	012	0	1	04	01	H3619_012_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3619	012	0	1	04	01	H3619_012_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	012	0	1	04	01	H3619_012_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	012	0	1	04	01	H3619_012_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H3619	012	0	1	04	01	H3619_012_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H3619	012	0	1	04	01	H3619_012_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H3619	012	0	1	04	01	H3619_012_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H3620	001	0	1	04	01	H3620_001_0	9	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			30								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H3620	001	0	1	04	01	H3620_001_0	9	3	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H3620	001	0	1	04	01	H3620_001_0	9	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H3620	001	0	1	04	01	H3620_001_0	9	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3623	001	0	1	01	01	H3623_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	001	0	1	01	01	H3623_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	001	0	1	01	01	H3623_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	001	0	1	01	01	H3623_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	001	0	1	01	01	H3623_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3623	002	0	1	01	01	H3623_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3623	002	0	1	01	01	H3623_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	002	0	1	01	01	H3623_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	002	0	1	01	01	H3623_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	002	0	1	01	01	H3623_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	003	0	1	01	01	H3623_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3623	003	0	1	01	01	H3623_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	003	0	1	01	01	H3623_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	003	0	1	01	01	H3623_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	003	0	1	01	01	H3623_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	004	0	1	01	01	H3623_004_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3623	004	0	1	01	01	H3623_004_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	004	0	1	01	01	H3623_004_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	004	0	1	01	01	H3623_004_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	004	0	1	01	01	H3623_004_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	005	0	1	01	01	H3623_005_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	005	0	1	01	01	H3623_005_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3623	005	0	1	01	01	H3623_005_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	005	0	1	01	01	H3623_005_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	005	0	1	01	01	H3623_005_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	006	0	1	01	01	H3623_006_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H3623	006	0	1	01	01	H3623_006_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H3623	006	0	1	01	01	H3623_006_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H3623	006	0	1	01	01	H3623_006_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H3623	006	0	1	01	01	H3623_006_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H3624	001	0	1	04	01	H3624_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3624	001	0	1	04	01	H3624_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H3624	001	0	1	04	01	H3624_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3624	001	0	1	04	01	H3624_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H3624	001	0	1	04	01	H3624_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H3624	002	0	1	04	01	H3624_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H3624	002	0	1	04	01	H3624_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H3624	002	0	1	04	01	H3624_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H3624	002	0	1	04	01	H3624_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H3624	002	0	1	04	01	H3624_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H3653	004	0	1	01	01	H3653_004_0	7	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	7.00	21.00								7.00			14.00								7.00
H3653	004	0	1	01	01	H3653_004_0	7	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			240.00								80.00
H3653	004	0	1	01	01	H3653_004_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00			70.00								35.00
H3653	004	0	1	01	01	H3653_004_0	7	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	7.00	21.00								7.00			14.00								7.00
H3653	004	0	1	01	01	H3653_004_0	7	6	4	3	Tier 6 - Specialty Drugs	010010	1	1	2			Tier 6 - Specialty Drugs																							Tier 6 - Specialty Drugs			Tier 6 - Specialty Drugs																						Tier 6 - Specialty Drugs																					
H3653	004	0	1	01	01	H3653_004_0	7	5	4	3	Tier 5 - Part D Eligible Injectables	010010	1	2	2			Tier 5 - Part D Eligible Injectables																							Tier 5 - Part D Eligible Injectables			Tier 5 - Part D Eligible Injectables																						Tier 5 - Part D Eligible Injectables																					
H3653	004	0	1	01	01	H3653_004_0	7	4	4	3	Tier 4 - Multisource Brand and Isomerics	000010	1	2	2			Tier 4 - Multisource Brand and Isomerics																							Tier 4 - Multisource Brand and Isomerics			Tier 4 - Multisource Brand and Isomerics																						Tier 4 - Multisource Brand and Isomerics																					
H3653	004	0	1	01	01	H3653_004_0	7	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H3653	004	0	1	01	01	H3653_004_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3653	004	0	1	01	01	H3653_004_0	7	4	4	1	Tier 4 - Multisource Brand and Isomerics	000010	1	2				Tier 4 - Multisource Brand and Isomerics	110000000010000000000	30									30											31	Tier 4 - Multisource Brand and Isomerics	2	2	Tier 4 - Multisource Brand and Isomerics																						Tier 4 - Multisource Brand and Isomerics	80.00									80.00											80.00
H3653	004	0	1	01	01	H3653_004_0	7	6	4	1	Tier 6 - Specialty Drugs	010010	1	1				Tier 6 - Specialty Drugs	110000000010000000000	30									30											31	Tier 6 - Specialty Drugs	2	1	Tier 6 - Specialty Drugs	33									33											33	Tier 6 - Specialty Drugs																					
H3653	004	0	1	01	01	H3653_004_0	7	5	4	1	Tier 5 - Part D Eligible Injectables	010010	1	2				Tier 5 - Part D Eligible Injectables	110000000010000000000	30									30											31	Tier 5 - Part D Eligible Injectables	2	1	Tier 5 - Part D Eligible Injectables	33									33											33	Tier 5 - Part D Eligible Injectables																					
H3653	015	0	1	01	01	H3653_015_0	7	3	4	1	Tier 3 - Part D Eligible Injectables	010010	1	2				Tier 3 - Part D Eligible Injectables	110000000010000000000	30									30											31	Tier 3 - Part D Eligible Injectables	2	1	Tier 3 - Part D Eligible Injectables	33									33											33	Tier 3 - Part D Eligible Injectables																					
H3653	015	0	1	01	01	H3653_015_0	7	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	10.00	30.00								10.00			20.00								10.00
H3653	015	0	1	01	01	H3653_015_0	7	2	4	1	Tier 2 - Brand	000010	1	2				Tier 2 - Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Brand	2	2	Tier 2 - Brand																						Tier 2 - Brand	40.00	120.00								40.00			80.00								40.00
H3653	015	0	1	01	01	H3653_015_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																					
H3655	013	0	1	01	01	H3655_013_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H3655	013	0	1	01	01	H3655_013_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3655	013	0	1	01	01	H3655_013_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3655	013	0	1	01	01	H3655_013_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H3655	013	0	1	01	01	H3655_013_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H3655	013	0	1	01	01	H3655_013_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3655	013	0	1	01	01	H3655_013_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H3655	013	0	1	01	01	H3655_013_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3655	013	0	1	01	01	H3655_013_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3655	013	0	1	01	01	H3655_013_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3655	023	0	1	01	01	H3655_023_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H3655	023	0	1	01	01	H3655_023_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H3655	023	0	1	01	01	H3655_023_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H3655	023	0	1	01	01	H3655_023_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H3655	023	0	1	01	01	H3655_023_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H3655	023	0	1	01	01	H3655_023_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H3655	023	0	1	01	01	H3655_023_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H3655	023	0	1	01	01	H3655_023_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H3655	023	0	1	01	01	H3655_023_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H3655	023	0	1	01	01	H3655_023_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H3659	001	0	1	02	01	H3659_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3659	001	0	1	02	01	H3659_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3659	001	0	1	02	01	H3659_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3659	001	0	1	02	01	H3659_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3659	003	0	1	01	01	H3659_003_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3659	003	0	1	01	01	H3659_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3659	003	0	1	01	01	H3659_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3659	003	0	1	01	01	H3659_003_0	5	4	4	1	Speciality	010010	1	1				Speciality	111000000010000010010	31	90								31					90			90			31	Speciality	2	1	Speciality	33	33								33						33			33		33	Speciality																					
H3659	003	0	1	01	01	H3659_003_0	5	4	4	3	Speciality	010010	1	1	2			Speciality																							Speciality			Speciality																						Speciality																					
H3659	003	0	1	01	01	H3659_003_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3659	003	0	1	01	01	H3659_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3659	003	0	1	01	01	H3659_003_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3659	031	0	1	01	01	H3659_031_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3659	031	0	1	01	01	H3659_031_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3659	031	0	1	01	01	H3659_031_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3659	031	0	1	01	01	H3659_031_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3659	057	0	1	01	01	H3659_057_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3659	057	0	1	01	01	H3659_057_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3659	057	0	1	01	01	H3659_057_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3659	057	0	1	01	01	H3659_057_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3659	058	0	1	01	01	H3659_058_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3659	058	0	1	01	01	H3659_058_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3659	058	0	1	01	01	H3659_058_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3659	058	0	1	01	01	H3659_058_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3659	059	0	1	01	01	H3659_059_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3659	059	0	1	01	01	H3659_059_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3659	059	0	1	01	01	H3659_059_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3659	059	0	1	01	01	H3659_059_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3659	059	0	1	01	01	H3659_059_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3659	059	0	1	01	01	H3659_059_0	4	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H3659	059	0	1	01	01	H3659_059_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3659	059	0	1	01	01	H3659_059_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3659	060	0	1	01	01	H3659_060_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3659	060	0	1	01	01	H3659_060_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3659	060	0	1	01	01	H3659_060_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3659	060	0	1	01	01	H3659_060_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3660	028	0	1	02	01	H3660_028_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3660	028	0	1	02	01	H3660_028_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	028	0	1	02	01	H3660_028_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	30	30								30			30								30	Tier 4																					
H3660	028	0	1	02	01	H3660_028_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	028	0	1	02	01	H3660_028_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H3660	028	0	1	02	01	H3660_028_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3660	028	0	1	02	01	H3660_028_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3660	028	0	1	02	01	H3660_028_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3660	029	0	1	02	01	H3660_029_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3660	029	0	1	02	01	H3660_029_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3660	029	0	1	02	01	H3660_029_0	8	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3660	029	0	1	02	01	H3660_029_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	029	0	1	02	01	H3660_029_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3660	029	0	1	02	01	H3660_029_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H3660	029	0	1	02	01	H3660_029_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	30	30								30			30								30	Tier 4																					
H3660	029	0	1	02	01	H3660_029_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	032	0	1	02	01	H3660_032_0	7	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H3660	032	0	1	02	01	H3660_032_0	7	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3660	032	0	1	02	01	H3660_032_0	7	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	032	0	1	02	01	H3660_032_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00
H3660	032	0	1	02	01	H3660_032_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H3660	032	0	1	02	01	H3660_032_0	7	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H3660	032	0	1	02	01	H3660_032_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	30	30								30			30								30	Tier 4																					
H3660	032	0	1	02	01	H3660_032_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H3664	001	0	1	02	01	H3664_001_0	5	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			30								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H3664	001	0	1	02	01	H3664_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H3664	001	0	1	02	01	H3664_001_0	5	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3664	001	0	1	02	01	H3664_001_0	5	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H3664	011	0	1	02	01	H3664_011_0	6	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H3664	011	0	1	02	01	H3664_011_0	6	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3664	011	0	1	02	01	H3664_011_0	6	3	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H3664	011	0	1	02	01	H3664_011_0	6	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			30								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H3664	012	0	1	02	01	H3664_012_0	5	1	4	3	Generic	011100	1	2	1		1	Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3664	012	0	1	02	01	H3664_012_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3664	012	0	1	02	01	H3664_012_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3664	012	0	1	02	01	H3664_012_0	5	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			60								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H3664	012	0	1	02	01	H3664_012_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H3664	012	0	1	02	01	H3664_012_0	5	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3664	012	0	1	02	01	H3664_012_0	5	4	4	3	Specialty	000001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3664	012	0	1	02	01	H3664_012_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H3664	016	0	1	02	01	H3664_016_0	6	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H3664	016	0	1	02	01	H3664_016_0	6	3	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H3664	016	0	1	02	01	H3664_016_0	6	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			30								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H3664	016	0	1	02	01	H3664_016_0	6	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H3668	005	0	1	01	01	H3668_005_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H3668	005	0	1	01	01	H3668_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00
H3668	005	0	1	01	01	H3668_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H3668	005	0	1	01	01	H3668_005_0	3	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3668	005	0	1	01	01	H3668_005_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H3668	005	0	1	01	01	H3668_005_0	3	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3668	005	0	1	01	01	H3668_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3668	005	0	1	01	01	H3668_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3668	011	0	1	01	01	H3668_011_0	5	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non Preferred Brand	1	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H3668	011	0	1	01	01	H3668_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H3668	011	0	1	01	01	H3668_011_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00		9.00	18.00								9.00
H3668	011	0	1	01	01	H3668_011_0	5	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3672	013	0	1	01	01	H3672_013_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H3672	013	0	1	01	01	H3672_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H3672	013	0	1	01	01	H3672_013_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
H3672	013	0	1	01	01	H3672_013_0	5	4	4	3	Specialty	010001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3672	013	0	1	01	01	H3672_013_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H3672	013	0	1	01	01	H3672_013_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3672	013	0	1	01	01	H3672_013_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3672	013	0	1	01	01	H3672_013_0	5	4	4	1	Specialty	010001	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	20									20		20									20	Specialty																					
H3706	001	0	1	01	01	H3706_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00											30.00
H3706	001	0	1	01	01	H3706_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H3706	001	0	1	01	01	H3706_001_0	3	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3706	001	0	1	01	01	H3706_001_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H3706	006	0	1	01	01	H3706_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H3706	006	0	1	01	01	H3706_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00											30.00
H3706	006	0	1	01	01	H3706_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H3706	006	0	1	01	01	H3706_006_0	3	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3706	014	0	1	01	01	H3706_014_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	112.50								45.00											45.00
H3706	014	0	1	01	01	H3706_014_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	50.00								20.00											20.00
H3706	014	0	1	01	01	H3706_014_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H3706	014	0	1	01	01	H3706_014_0	3	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3706	014	0	1	01	01	H3706_014_0	3	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3706	014	0	1	01	01	H3706_014_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3706	014	0	1	01	01	H3706_014_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3706	014	0	1	01	01	H3706_014_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H3706	015	0	1	01	01	H3706_015_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H3706	015	0	1	01	01	H3706_015_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	62.50								25.00											25.00
H3706	015	0	1	01	01	H3706_015_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	125.00								50.00											50.00
H3706	015	0	1	01	01	H3706_015_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3706	015	0	1	01	01	H3706_015_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3706	015	0	1	01	01	H3706_015_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H3706	015	0	1	01	01	H3706_015_0	4	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3706	015	0	1	01	01	H3706_015_0	4	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3706	016	0	1	01	01	H3706_016_0	4	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3706	016	0	1	01	01	H3706_016_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	125.00								50.00											50.00
H3706	016	0	1	01	01	H3706_016_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	62.50								25.00											25.00
H3706	016	0	1	01	01	H3706_016_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H3706	016	0	1	01	01	H3706_016_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H3706	016	0	1	01	01	H3706_016_0	4	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3706	016	0	1	01	01	H3706_016_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3706	016	0	1	01	01	H3706_016_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3706	017	0	1	01	01	H3706_017_0	3	4	4	1	Specialty	110001	1	1				Specialty	111000000010000000000	31	90								31											31	Specialty	2	1	Specialty	25	25								25											25	Specialty																					
H3706	017	0	1	01	01	H3706_017_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	125.00								50.00											50.00
H3706	017	0	1	01	01	H3706_017_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	62.50								25.00											25.00
H3706	017	0	1	01	01	H3706_017_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H3706	017	0	1	01	01	H3706_017_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H3706	017	0	1	01	01	H3706_017_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3706	017	0	1	01	01	H3706_017_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3706	017	0	1	01	01	H3706_017_0	3	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3709	001	0	1	04	01	H3709_001_0	8	4	3	1	Non-specialty injectables	010010		2				Non-specialty injectables	111000000010110000000	30	90								30		30								90	31	Non-specialty injectables	2	1	Non-specialty injectables	30	30								30		30	30								30	Non-specialty injectables																					
H3709	001	0	1	04	01	H3709_001_0	8	3	3	1	Non-Preferred Brand and Non-Preferred Generic	100100		2				Non-Preferred Brand and Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand and Non-Preferred Generic	2	2	Non-Preferred Brand and Non-Preferred Generic																						Non-Preferred Brand and Non-Preferred Generic	63.00	189.00								63.00		63.00	189.00								63.00
H3709	001	0	1	04	01	H3709_001_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
H3709	001	0	1	04	01	H3709_001_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00		7.00	21.00								7.00
H3709	001	0	1	04	01	H3709_001_0	8	5	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010110000000	30	90								30		30								90	31	Specialty drugs	2	1	Specialty drugs	30	30								30		30	30								30	Specialty drugs																					
H3749	001	0	1	01	01	H3749_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	001	0	1	01	01	H3749_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3749	001	0	1	01	01	H3749_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3749	001	0	1	01	01	H3749_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	001	0	1	01	01	H3749_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	001	0	1	01	01	H3749_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3749	001	0	1	01	01	H3749_001_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3749	001	0	1	01	01	H3749_001_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H3749	004	0	1	01	01	H3749_004_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3749	004	0	1	01	01	H3749_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	004	0	1	01	01	H3749_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3749	004	0	1	01	01	H3749_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	013	0	1	01	01	H3749_013_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	013	0	1	01	01	H3749_013_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	013	0	1	01	01	H3749_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3749	013	0	1	01	01	H3749_013_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3749	014	0	1	01	01	H3749_014_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	014	0	1	01	01	H3749_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3749	014	0	1	01	01	H3749_014_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3749	014	0	1	01	01	H3749_014_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	015	0	1	01	01	H3749_015_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	015	0	1	01	01	H3749_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3749	015	0	1	01	01	H3749_015_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	015	0	1	01	01	H3749_015_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3749	016	0	1	01	01	H3749_016_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3749	016	0	1	01	01	H3749_016_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3749	016	0	1	01	01	H3749_016_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3749	016	0	1	01	01	H3749_016_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	017	0	1	01	01	H3749_017_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3749	017	0	1	01	01	H3749_017_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3749	017	0	1	01	01	H3749_017_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3749	017	0	1	01	01	H3749_017_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3755	001	0	1	01	01	H3755_001_0	5	2	4	1	Preferred Generics	001000	1	2				Preferred Generics	111000000010110000000	30	90								30		30								90	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	5.00	15.00								5.00		5.00	15.00								5.00
H3755	001	0	1	01	01	H3755_001_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H3755	001	0	1	01	01	H3755_001_0	5	4	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	111000000010110000000	30	90								30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs	90.00	270.00								90.00		90.00	270.00								90.00
H3755	001	0	1	01	01	H3755_001_0	5	5	4	1	Non-Specialty Injectables	111111	1	2				Non-Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Non-Specialty Injectables	2	1	Non-Specialty Injectables	33	33								33		33	33								33	Non-Specialty Injectables																					
H3755	001	0	1	01	01	H3755_001_0	5	6	4	1	Specialty Drugs	111111	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33		33	33								33	Specialty Drugs																					
H3755	001	0	1	01	01	H3755_001_0	5	1	4	1	Select Generics	001000	1	2				Select Generics	111000000010110000000	30	90								30		30								90	31	Select Generics	2	2	Select Generics																						Select Generics	0.00	0.00								0.00		0.00	0.00								0.00
H3755	004	0	1	01	01	H3755_004_0	5	6	4	1	Specialty Drugs	111111	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33		33	33								33	Specialty Drugs																					
H3755	004	0	1	01	01	H3755_004_0	5	5	4	1	Non-Specialty Injectables	111111	1	2				Non-Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Non-Specialty Injectables	2	1	Non-Specialty Injectables	33	33								33		33	33								33	Non-Specialty Injectables																					
H3755	004	0	1	01	01	H3755_004_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H3755	004	0	1	01	01	H3755_004_0	5	2	4	1	Preferred Generics	001000	1	2				Preferred Generics	111000000010110000000	30	90								30		30								90	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	5.00	15.00								5.00		5.00	15.00								5.00
H3755	004	0	1	01	01	H3755_004_0	5	1	4	1	Select Generics	001000	1	2				Select Generics	111000000010110000000	30	90								30		30								90	31	Select Generics	2	2	Select Generics																						Select Generics	0.00	0.00								0.00		0.00	0.00								0.00
H3755	004	0	1	01	01	H3755_004_0	5	4	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	111000000010110000000	30	90								30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs	90.00	270.00								90.00		90.00	270.00								90.00
H3805	001	0	1	01	01	H3805_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3805	001	0	1	01	01	H3805_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3805	001	0	1	01	01	H3805_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3805	001	0	1	01	01	H3805_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3805	007	0	1	01	01	H3805_007_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3805	007	0	1	01	01	H3805_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H3805	007	0	1	01	01	H3805_007_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H3805	007	0	1	01	01	H3805_007_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3810	003	0	1	01	01	H3810_003_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3810	003	0	1	01	01	H3810_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	003	0	1	01	01	H3810_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	003	0	1	01	01	H3810_003_0	6	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	005	0	1	02	01	H3810_005_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3810	005	0	1	02	01	H3810_005_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	005	0	1	02	01	H3810_005_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	005	0	1	02	01	H3810_005_0	6	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	007	0	1	01	01	H3810_007_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	007	0	1	01	01	H3810_007_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3810	007	0	1	01	01	H3810_007_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	007	0	1	01	01	H3810_007_0	8	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	010	0	1	01	01	H3810_010_0	6	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	010	0	1	01	01	H3810_010_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3810	010	0	1	01	01	H3810_010_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	010	0	1	01	01	H3810_010_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	012	0	1	02	01	H3810_012_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3810	012	0	1	02	01	H3810_012_0	6	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	012	0	1	02	01	H3810_012_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	012	0	1	02	01	H3810_012_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	014	0	1	01	01	H3810_014_0	6	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3810	014	0	1	01	01	H3810_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	59.00	118.00								59.00		59.00	118.00								59.00
H3810	014	0	1	01	01	H3810_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00		29.00	58.00								29.00
H3810	014	0	1	01	01	H3810_014_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00		5.00	10.00								5.00
H3811	002	0	1	01	01	H3811_002_0	6	3	3	1	Preferred Brands Tier	000001		2				Preferred Brands Tier	111000000010010000000	34	90								34										90	31	Preferred Brands Tier	2	2	Preferred Brands Tier																						Preferred Brands Tier	36.00	108.00								36.00			108.00								36.00
H3811	002	0	1	01	01	H3811_002_0	6	2	3	1	Generic Tier	010000		2				Generic Tier	111000000010010000000	34	90								34										90	31	Generic Tier	2	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00
H3811	002	0	1	01	01	H3811_002_0	6	5	3	1	Non-Preferred Brands Tier	100000		2				Non-Preferred Brands Tier	111000000010010000000	34	90								34										90	31	Non-Preferred Brands Tier	2	2	Non-Preferred Brands Tier																						Non-Preferred Brands Tier	75.00	225.00								75.00			225.00								75.00
H3811	002	0	1	01	01	H3811_002_0	6	4	3	1	Speciality Tier	000010		1				Speciality Tier	110000000010000000000	34									34											31	Speciality Tier	2	1	Speciality Tier	30									30											30	Speciality Tier																					
H3811	002	0	1	01	01	H3811_002_0	6	1	3	1	Therapeutic Tier	010000		2				Therapeutic Tier	111000000010010000000	34	90								34										90	31	Therapeutic Tier	2	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00
H3811	009	0	1	01	01	H3811_009_0	5	5	4	1	Non-Preferred Brands Tier	100000	1	2				Non-Preferred Brands Tier	111000000010010000000	34	90								34										90	31	Non-Preferred Brands Tier	2	2	Non-Preferred Brands Tier																						Non-Preferred Brands Tier	75.00	225.00								75.00			225.00								75.00
H3811	009	0	1	01	01	H3811_009_0	5	4	4	1	Speciality Tier	000010	1	1				Speciality Tier	110000000010000000000	34									34											31	Speciality Tier	2	1	Speciality Tier	30									30											30	Speciality Tier																					
H3811	009	0	1	01	01	H3811_009_0	5	3	4	1	Preferred Brands Tier	000001	1	2				Preferred Brands Tier	111000000010010000000	34	90								34										90	31	Preferred Brands Tier	2	2	Preferred Brands Tier																						Preferred Brands Tier	36.00	108.00								36.00			108.00								36.00
H3811	009	0	1	01	01	H3811_009_0	5	2	4	1	Generic Tier	010000	1	2				Generic Tier	111000000010010000000	34	90								34										90	31	Generic Tier	2	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00
H3811	009	0	1	01	01	H3811_009_0	5	1	4	3	Therapeutic Tier	010000	1	2	1		1	Therapeutic Tier	111000000010010000000	34	90								34										90	31	Therapeutic Tier	2	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00
H3811	009	0	1	01	01	H3811_009_0	5	2	4	3	Generic Tier	010000	1	2	1		1	Generic Tier	111000000010010000000	34	90								34										90	31	Generic Tier	2	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00
H3811	009	0	1	01	01	H3811_009_0	5	1	4	1	Therapeutic Tier	010000	1	2				Therapeutic Tier	111000000010010000000	34	90								34										90	31	Therapeutic Tier	2	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00
H3811	009	0	1	01	01	H3811_009_0	5	4	4	3	Speciality Tier	000010	1	1	2			Speciality Tier																							Speciality Tier			Speciality Tier																						Speciality Tier																					
H3811	009	0	1	01	01	H3811_009_0	5	5	4	3	Non-Preferred Brands Tier	100000	1	2	2			Non-Preferred Brands Tier																							Non-Preferred Brands Tier			Non-Preferred Brands Tier																						Non-Preferred Brands Tier																					
H3811	009	0	1	01	01	H3811_009_0	5	3	4	3	Preferred Brands Tier	000001	1	2	2			Preferred Brands Tier																							Preferred Brands Tier			Preferred Brands Tier																						Preferred Brands Tier																					
H3812	001	0	1	04	01	H3812_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3812	001	0	1	04	01	H3812_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H3812	001	0	1	04	01	H3812_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H3812	001	0	1	04	01	H3812_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H3812	005	0	1	04	01	H3812_005_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3812	005	0	1	04	01	H3812_005_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3812	005	0	1	04	01	H3812_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3812	005	0	1	04	01	H3812_005_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3812	007	0	1	04	01	H3812_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3812	007	0	1	04	01	H3812_007_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3812	007	0	1	04	01	H3812_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3812	007	0	1	04	01	H3812_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3813	003	0	1	04	01	H3813_003_0	9	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H3813	003	0	1	04	01	H3813_003_0	9	1	4	3	Tier  1	010000	1	2	1		1	Tier  1	111000000010110000000	30	90								30		30								90	31	Tier  1	2	1	Tier  1	25	25								25		25	25								25	Tier  1																					
H3814	004	0	1	01	01	H3814_004_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	004	0	1	01	01	H3814_004_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	004	0	1	01	01	H3814_004_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	004	0	1	01	01	H3814_004_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	006	0	1	01	01	H3814_006_0	9	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	006	0	1	01	01	H3814_006_0	9	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	006	0	1	01	01	H3814_006_0	9	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	006	0	1	01	01	H3814_006_0	9	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	008	0	1	01	01	H3814_008_0	9	4	4	1	TIER 4 - SPECIALTY	100000	1	1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	008	0	1	01	01	H3814_008_0	9	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	008	0	1	01	01	H3814_008_0	9	4	4	3	TIER 4 - SPECIALTY	100000	1	1	2			TIER 4 - SPECIALTY																							TIER 4 - SPECIALTY			TIER 4 - SPECIALTY																						TIER 4 - SPECIALTY																					
H3814	008	0	1	01	01	H3814_008_0	9	3	4	3	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2			TIER 3 - NON-PREFERRED BRAND																							TIER 3 - NON-PREFERRED BRAND			TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND																					
H3814	008	0	1	01	01	H3814_008_0	9	2	4	3	TIER 2 - PREFERRED BRAND	000001	1	2	2			TIER 2 - PREFERRED BRAND																							TIER 2 - PREFERRED BRAND			TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND																					
H3814	008	0	1	01	01	H3814_008_0	9	1	4	3	TIER 1 - GENERICS	010000	1	2	1		1	TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	008	0	1	01	01	H3814_008_0	9	1	4	1	TIER 1 - GENERICS	010000	1	2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	008	0	1	01	01	H3814_008_0	9	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2				TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 - PREFERRED BRAND	2	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	012	0	1	01	01	H3814_012_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	012	0	1	01	01	H3814_012_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	012	0	1	01	01	H3814_012_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	012	0	1	01	01	H3814_012_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	015	0	1	02	01	H3814_015_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	015	0	1	02	01	H3814_015_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	015	0	1	02	01	H3814_015_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	015	0	1	02	01	H3814_015_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	016	0	1	02	01	H3814_016_0	9	4	4	3	TIER 4 - SPECIALTY	100000	1	1	2			TIER 4 - SPECIALTY																							TIER 4 - SPECIALTY			TIER 4 - SPECIALTY																						TIER 4 - SPECIALTY																					
H3814	016	0	1	02	01	H3814_016_0	9	3	4	3	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2			TIER 3 - NON-PREFERRED BRAND																							TIER 3 - NON-PREFERRED BRAND			TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND																					
H3814	016	0	1	02	01	H3814_016_0	9	1	4	3	TIER 1 - GENERICS	010000	1	2	1		1	TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00
H3814	016	0	1	02	01	H3814_016_0	9	2	4	3	TIER 2 - PREFERRED BRAND	000001	1	2	2			TIER 2 - PREFERRED BRAND																							TIER 2 - PREFERRED BRAND			TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND																					
H3814	016	0	1	02	01	H3814_016_0	9	4	4	1	TIER 4 - SPECIALTY	100000	1	1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	20	20								20		20	20								20	TIER 4 - SPECIALTY																					
H3814	016	0	1	02	01	H3814_016_0	9	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	35.00	105.00								35.00		35.00	70.00								35.00
H3814	016	0	1	02	01	H3814_016_0	9	1	4	1	TIER 1 - GENERICS	010000	1	2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00
H3814	016	0	1	02	01	H3814_016_0	9	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2				TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 - PREFERRED BRAND	2	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	20.00	60.00								20.00		20.00	40.00								20.00
H3814	019	0	1	01	01	H3814_019_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	019	0	1	01	01	H3814_019_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	019	0	1	01	01	H3814_019_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	019	0	1	01	01	H3814_019_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	021	0	1	02	01	H3814_021_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	021	0	1	02	01	H3814_021_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3814	021	0	1	02	01	H3814_021_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	021	0	1	02	01	H3814_021_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	024	0	1	01	01	H3814_024_0	8	2	2	1	TIER 2 PREFERRED BRAND	000001		2				TIER 2 PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 2 PREFERRED BRAND	2	2	TIER 2 PREFERRED BRAND																						TIER 2 PREFERRED BRAND	34.00	102.00								34.00		34.00	68.00								34.00
H3814	024	0	1	01	01	H3814_024_0	8	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2				TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31								90	31	TIER 3 - NON-PREFERRED BRAND	2	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00
H3814	024	0	1	01	01	H3814_024_0	8	1	2	1	TIER 1 - GENERICS	010000		2				TIER 1 - GENERICS	111000000010110000000	31	90								31		31								90	31	TIER 1 - GENERICS	2	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	7.00	21.00								7.00		7.00	14.00								7.00
H3814	024	0	1	01	01	H3814_024_0	8	4	2	1	TIER 4 - SPECIALTY	100000		1				TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31								90	31	TIER 4 - SPECIALTY	2	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																					
H3815	001	0	1	01	01	H3815_001_0	9	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010010000000	30	90								30										90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00			0.00								0.00
H3815	001	0	1	01	01	H3815_001_0	9	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010010000000	30	90								30										90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	15.00	45.00								15.00			30.00								15.00
H3815	001	0	1	01	01	H3815_001_0	9	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	25.00	75.00								25.00			50.00								25.00
H3815	001	0	1	01	01	H3815_001_0	9	4	4	1	Formulary Specialty	110001	1	1				Formulary Specialty	111000000010000000000	30	90								30											31	Formulary Specialty	2	1	Formulary Specialty	25	25								25											25	Formulary Specialty																					
H3817	002	0	1	04	01	H3817_002_0	6	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H3817	002	0	1	04	01	H3817_002_0	6	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H3817	002	0	1	04	01	H3817_002_0	6	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H3817	002	0	1	04	01	H3817_002_0	6	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H3817	002	0	1	04	01	H3817_002_0	6	5	2	1	Specialty Medications	110001		1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H3817	003	0	1	04	01	H3817_003_0	9	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H3817	003	0	1	04	01	H3817_003_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H3817	003	0	1	04	01	H3817_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H3817	003	0	1	04	01	H3817_003_0	9	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H3817	003	0	1	04	01	H3817_003_0	9	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
H3817	003	0	1	04	01	H3817_003_0	9	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H3817	003	0	1	04	01	H3817_003_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3817	003	0	1	04	01	H3817_003_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3817	003	0	1	04	01	H3817_003_0	9	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
H3817	003	0	1	04	01	H3817_003_0	9	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H3817	006	0	1	04	01	H3817_006_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H3817	006	0	1	04	01	H3817_006_0	6	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H3817	006	0	1	04	01	H3817_006_0	6	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H3817	006	0	1	04	01	H3817_006_0	6	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H3817	006	0	1	04	01	H3817_006_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H3818	001	0	1	01	01	H3818_001_0	7	1	4	1	Generic	001000	1	2				Generic	111000000001110000000	31	90									10	31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	10.00								5.00
H3818	001	0	1	01	01	H3818_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	31	90									10	31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00	30.00	60.00								30.00
H3818	001	0	1	01	01	H3818_001_0	7	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000001110000000	31	90									10	31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00									60.00	60.00	120.00								60.00
H3818	001	0	1	01	01	H3818_001_0	7	4	4	1	Specialty	001001	1	1				Specialty	111000000001110000000	31	90									10	31								90	31	Specialty	2	1	Specialty	33	33									33	33	33								33	Specialty																					
H3818	003	0	1	01	01	H3818_003_0	7	1	4	1	Generic	001000	1	2				Generic	111000000001110000000	31	90									10	31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	10.00								5.00
H3818	003	0	1	01	01	H3818_003_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	31	90									10	31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00	30.00	60.00								30.00
H3818	003	0	1	01	01	H3818_003_0	7	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000001110000000	31	90									10	31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00									60.00	60.00	120.00								60.00
H3818	003	0	1	01	01	H3818_003_0	7	4	4	1	Specialty	001001	1	1				Specialty	111000000001110000000	31	90									10	31								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H3864	006	0	1	01	01	H3864_006_0	6	3	3	1	Specialty	010010		1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3864	006	0	1	01	01	H3864_006_0	6	2	3	1	Brand	000010		2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	33.50	67.00								33.50			67.00								33.50
H3864	006	0	1	01	01	H3864_006_0	6	1	3	1	Generc	010000		2				Generc	111000000010010000000	31	90								31										90	31	Generc	2	2	Generc																						Generc	10.00	20.00								10.00			20.00								10.00
H3864	007	0	1	02	01	H3864_007_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	110.00								55.00			110.00								55.00
H3864	007	0	1	02	01	H3864_007_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H3864	007	0	1	02	01	H3864_007_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H3864	007	0	1	02	01	H3864_007_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H3887	001	0	1	02	01	H3887_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3887	001	0	1	02	01	H3887_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3887	001	0	1	02	01	H3887_001_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3887	001	0	1	02	01	H3887_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3887	003	0	1	02	01	H3887_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3887	003	0	1	02	01	H3887_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H3887	003	0	1	02	01	H3887_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3887	003	0	1	02	01	H3887_003_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H3887	005	0	1	02	01	H3887_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3887	005	0	1	02	01	H3887_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3887	005	0	1	02	01	H3887_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3887	005	0	1	02	01	H3887_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3907	006	0	1	01	01	H3907_006_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H3907	006	0	1	01	01	H3907_006_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H3907	006	0	1	01	01	H3907_006_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H3907	006	0	1	01	01	H3907_006_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H3907	020	0	1	01	01	H3907_020_0	5	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H3907	020	0	1	01	01	H3907_020_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00
H3907	020	0	1	01	01	H3907_020_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00
H3907	020	0	1	01	01	H3907_020_0	5	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3907	029	0	1	01	01	H3907_029_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
H3907	029	0	1	01	01	H3907_029_0	5	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H3907	029	0	1	01	01	H3907_029_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00
H3907	029	0	1	01	01	H3907_029_0	5	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H3909	001	0	1	04	01	H3909_001_0	8	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3909	001	0	1	04	01	H3909_001_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	69.00								23.00			46.00								23.00
H3909	001	0	1	04	01	H3909_001_0	8	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H3909	001	0	1	04	01	H3909_001_0	8	4	3	1	Specialty	110001		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3912	001	0	1	04	01	H3912_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H3912	001	0	1	04	01	H3912_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H3912	001	0	1	04	01	H3912_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3912	001	0	1	04	01	H3912_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3912	008	0	1	04	01	H3912_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3912	008	0	1	04	01	H3912_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3912	008	0	1	04	01	H3912_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3912	008	0	1	04	01	H3912_008_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3912	009	0	1	04	01	H3912_009_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3912	009	0	1	04	01	H3912_009_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3912	009	0	1	04	01	H3912_009_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3912	009	0	1	04	01	H3912_009_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3912	011	0	1	04	01	H3912_011_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3912	011	0	1	04	01	H3912_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H3912	011	0	1	04	01	H3912_011_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3912	011	0	1	04	01	H3912_011_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H3916	001	0	1	04	01	H3916_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	001	0	1	04	01	H3916_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H3916	001	0	1	04	01	H3916_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H3916	001	0	1	04	01	H3916_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	002	0	1	04	01	H3916_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	002	0	1	04	01	H3916_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H3916	002	0	1	04	01	H3916_002_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	002	0	1	04	01	H3916_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H3916	003	0	1	04	01	H3916_003_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	003	0	1	04	01	H3916_003_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H3916	003	0	1	04	01	H3916_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H3916	003	0	1	04	01	H3916_003_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	005	0	1	04	01	H3916_005_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		162.50	162.50								65.00
H3916	005	0	1	04	01	H3916_005_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3916	005	0	1	04	01	H3916_005_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	005	0	1	04	01	H3916_005_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	005	0	1	04	01	H3916_005_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3916	005	0	1	04	01	H3916_005_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3916	005	0	1	04	01	H3916_005_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3916	005	0	1	04	01	H3916_005_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	015	0	1	04	01	H3916_015_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	015	0	1	04	01	H3916_015_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00
H3916	015	0	1	04	01	H3916_015_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00
H3916	015	0	1	04	01	H3916_015_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	018	0	1	04	01	H3916_018_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	018	0	1	04	01	H3916_018_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00
H3916	018	0	1	04	01	H3916_018_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	018	0	1	04	01	H3916_018_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00
H3916	019	0	1	04	01	H3916_019_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	019	0	1	04	01	H3916_019_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	019	0	1	04	01	H3916_019_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	019	0	1	04	01	H3916_019_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	020	0	1	04	01	H3916_020_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	020	0	1	04	01	H3916_020_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	020	0	1	04	01	H3916_020_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	020	0	1	04	01	H3916_020_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	021	0	1	04	01	H3916_021_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	021	0	1	04	01	H3916_021_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	021	0	1	04	01	H3916_021_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	021	0	1	04	01	H3916_021_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	022	0	1	04	01	H3916_022_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	022	0	1	04	01	H3916_022_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	022	0	1	04	01	H3916_022_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	022	0	1	04	01	H3916_022_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	023	0	1	04	01	H3916_023_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	023	0	1	04	01	H3916_023_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	023	0	1	04	01	H3916_023_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	023	0	1	04	01	H3916_023_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	024	0	1	04	01	H3916_024_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	024	0	1	04	01	H3916_024_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	024	0	1	04	01	H3916_024_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	024	0	1	04	01	H3916_024_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	025	0	1	04	01	H3916_025_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3916	025	0	1	04	01	H3916_025_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00		95.00	95.00								38.00
H3916	025	0	1	04	01	H3916_025_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	025	0	1	04	01	H3916_025_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00		170.00	170.00								68.00
H3916	026	0	1	04	01	H3916_026_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	026	0	1	04	01	H3916_026_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H3916	026	0	1	04	01	H3916_026_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3916	026	0	1	04	01	H3916_026_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3916	026	0	1	04	01	H3916_026_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3916	026	0	1	04	01	H3916_026_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3916	026	0	1	04	01	H3916_026_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	026	0	1	04	01	H3916_026_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	027	0	1	04	01	H3916_027_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3916	027	0	1	04	01	H3916_027_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	027	0	1	04	01	H3916_027_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3916	027	0	1	04	01	H3916_027_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3916	027	0	1	04	01	H3916_027_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	027	0	1	04	01	H3916_027_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H3916	027	0	1	04	01	H3916_027_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3916	027	0	1	04	01	H3916_027_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	028	0	1	04	01	H3916_028_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H3916	028	0	1	04	01	H3916_028_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3916	028	0	1	04	01	H3916_028_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	028	0	1	04	01	H3916_028_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H3916	028	0	1	04	01	H3916_028_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3916	028	0	1	04	01	H3916_028_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3916	028	0	1	04	01	H3916_028_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H3916	028	0	1	04	01	H3916_028_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3920	001	0	1	01	01	H3920_001_0	10	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3920	001	0	1	01	01	H3920_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H3920	001	0	1	01	01	H3920_001_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H3920	001	0	1	01	01	H3920_001_0	10	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H3920	002	0	1	01	01	H3920_002_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H3920	002	0	1	01	01	H3920_002_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3920	002	0	1	01	01	H3920_002_0	8	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3920	002	0	1	01	01	H3920_002_0	8	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H3920	002	0	1	01	01	H3920_002_0	8	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H3920	002	0	1	01	01	H3920_002_0	8	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H3920	002	0	1	01	01	H3920_002_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H3920	002	0	1	01	01	H3920_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H3921	001	0	1	04	01	H3921_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3921	001	0	1	04	01	H3921_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3921	001	0	1	04	01	H3921_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H3921	001	0	1	04	01	H3921_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H3921	003	0	1	04	01	H3921_003_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H3921	003	0	1	04	01	H3921_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H3921	003	0	1	04	01	H3921_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3921	003	0	1	04	01	H3921_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3921	008	0	1	04	01	H3921_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H3921	008	0	1	04	01	H3921_008_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H3921	008	0	1	04	01	H3921_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H3921	008	0	1	04	01	H3921_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H3923	013	0	1	04	01	H3923_013_0	9	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3923	013	0	1	04	01	H3923_013_0	9	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Preferred Brand Drugs	1	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	85.00								35.00			85.00								35.00
H3923	013	0	1	04	01	H3923_013_0	9	3	4	1	Non-Preferred Brand Drugs	100000	3	2				Non-Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Non-Preferred Brand Drugs	1	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	85.00	210.00								85.00			210.00								85.00
H3923	013	0	1	04	01	H3923_013_0	9	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3923	013	0	1	04	01	H3923_013_0	9	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3923	013	0	1	04	01	H3923_013_0	9	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H3923	013	0	1	04	01	H3923_013_0	9	3	4	3	Non-Preferred Brand Drugs	100000	3	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H3923	013	0	1	04	01	H3923_013_0	9	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3923	017	0	1	04	01	H3923_017_0	8	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3923	017	0	1	04	01	H3923_017_0	8	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Preferred Brand Drugs	1	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	85.00								35.00			85.00								35.00
H3923	017	0	1	04	01	H3923_017_0	8	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3923	017	0	1	04	01	H3923_017_0	8	3	4	3	Non-Preferred Brand Drugs	100000	3	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H3923	017	0	1	04	01	H3923_017_0	8	3	4	1	Non-Preferred Brand Drugs	100000	3	2				Non-Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Non-Preferred Brand Drugs	1	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	85.00	210.00								85.00			210.00								85.00
H3923	017	0	1	04	01	H3923_017_0	8	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3923	017	0	1	04	01	H3923_017_0	8	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3923	017	0	1	04	01	H3923_017_0	8	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H3923	021	0	1	04	01	H3923_021_0	9	2	4	1	Formulary Brand Drugs	000001	1	2				Formulary Brand Drugs	111000000010010000000	34	90								34										90	34	Formulary Brand Drugs	1	2	Formulary Brand Drugs																						Formulary Brand Drugs	40.00	100.00								40.00			100.00								40.00
H3923	021	0	1	04	01	H3923_021_0	9	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	9.00	25.00								9.00			25.00								9.00
H3923	021	0	1	04	01	H3923_021_0	9	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3924	003	0	1	04	01	H3924_003_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	003	0	1	04	01	H3924_003_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	003	0	1	04	01	H3924_003_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	003	0	1	04	01	H3924_003_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	007	0	1	04	01	H3924_007_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	007	0	1	04	01	H3924_007_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	007	0	1	04	01	H3924_007_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	007	0	1	04	01	H3924_007_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	011	0	1	04	01	H3924_011_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	011	0	1	04	01	H3924_011_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	011	0	1	04	01	H3924_011_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	011	0	1	04	01	H3924_011_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	015	0	1	04	01	H3924_015_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	015	0	1	04	01	H3924_015_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	015	0	1	04	01	H3924_015_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	015	0	1	04	01	H3924_015_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	019	0	1	04	01	H3924_019_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	019	0	1	04	01	H3924_019_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	019	0	1	04	01	H3924_019_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	019	0	1	04	01	H3924_019_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	023	0	1	04	01	H3924_023_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	023	0	1	04	01	H3924_023_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	023	0	1	04	01	H3924_023_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	023	0	1	04	01	H3924_023_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	027	0	1	04	01	H3924_027_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	027	0	1	04	01	H3924_027_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	027	0	1	04	01	H3924_027_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	027	0	1	04	01	H3924_027_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	031	0	1	04	01	H3924_031_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	031	0	1	04	01	H3924_031_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	031	0	1	04	01	H3924_031_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	031	0	1	04	01	H3924_031_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	035	0	1	04	01	H3924_035_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	035	0	1	04	01	H3924_035_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	035	0	1	04	01	H3924_035_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	035	0	1	04	01	H3924_035_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	038	0	1	04	01	H3924_038_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	038	0	1	04	01	H3924_038_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	038	0	1	04	01	H3924_038_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	038	0	1	04	01	H3924_038_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	041	0	1	04	01	H3924_041_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3924	041	0	1	04	01	H3924_041_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	041	0	1	04	01	H3924_041_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	041	0	1	04	01	H3924_041_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	044	0	1	04	01	H3924_044_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3924	044	0	1	04	01	H3924_044_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3924	044	0	1	04	01	H3924_044_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3924	044	0	1	04	01	H3924_044_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3931	004	0	1	01	01	H3931_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3931	004	0	1	01	01	H3931_004_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3931	004	0	1	01	01	H3931_004_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3931	004	0	1	01	01	H3931_004_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	004	0	1	01	01	H3931_004_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	058	0	1	01	01	H3931_058_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3931	058	0	1	01	01	H3931_058_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3931	058	0	1	01	01	H3931_058_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3931	058	0	1	01	01	H3931_058_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	058	0	1	01	01	H3931_058_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	064	0	1	01	01	H3931_064_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				7.00	17.50		7.00	21.00			7.00					14.00			21.00		7.00
H3931	064	0	1	01	01	H3931_064_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				13.00	32.50		13.00	39.00			13.00					26.00			39.00		13.00
H3931	064	0	1	01	01	H3931_064_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H3931	064	0	1	01	01	H3931_064_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				67.00	167.50		67.00	201.00			67.00					134.00			201.00		67.00
H3931	064	0	1	01	01	H3931_064_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	065	0	1	01	01	H3931_065_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	065	0	1	01	01	H3931_065_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H3931	065	0	1	01	01	H3931_065_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				24.00	60.00		24.00	72.00			24.00					48.00			72.00		24.00
H3931	065	0	1	01	01	H3931_065_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H3931	065	0	1	01	01	H3931_065_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H3931	069	0	1	01	01	H3931_069_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				70.00	175.00		70.00	210.00			70.00					140.00			210.00		70.00
H3931	069	0	1	01	01	H3931_069_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	069	0	1	01	01	H3931_069_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					58.00			87.00		29.00
H3931	069	0	1	01	01	H3931_069_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3931	069	0	1	01	01	H3931_069_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3931	070	0	1	01	01	H3931_070_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	070	0	1	01	01	H3931_070_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H3931	070	0	1	01	01	H3931_070_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H3931	070	0	1	01	01	H3931_070_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H3931	070	0	1	01	01	H3931_070_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	071	0	1	01	01	H3931_071_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3931	071	0	1	01	01	H3931_071_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3931	071	0	1	01	01	H3931_071_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3931	071	0	1	01	01	H3931_071_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H3931	071	0	1	01	01	H3931_071_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H3931	071	0	1	01	01	H3931_071_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H3931	071	0	1	01	01	H3931_071_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3931	071	0	1	01	01	H3931_071_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3931	071	0	1	01	01	H3931_071_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3931	071	0	1	01	01	H3931_071_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H3931	075	0	1	01	01	H3931_075_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	075	0	1	01	01	H3931_075_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H3931	075	0	1	01	01	H3931_075_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H3931	075	0	1	01	01	H3931_075_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	075	0	1	01	01	H3931_075_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H3931	076	0	1	01	01	H3931_076_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H3931	076	0	1	01	01	H3931_076_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H3931	076	0	1	01	01	H3931_076_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3931	076	0	1	01	01	H3931_076_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H3931	076	0	1	01	01	H3931_076_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H3931	076	0	1	01	01	H3931_076_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H3931	076	0	1	01	01	H3931_076_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H3931	076	0	1	01	01	H3931_076_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H3931	076	0	1	01	01	H3931_076_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H3931	076	0	1	01	01	H3931_076_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H3931	077	0	1	01	01	H3931_077_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	077	0	1	01	01	H3931_077_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3931	077	0	1	01	01	H3931_077_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3931	077	0	1	01	01	H3931_077_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3931	077	0	1	01	01	H3931_077_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	078	0	1	01	01	H3931_078_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H3931	078	0	1	01	01	H3931_078_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H3931	078	0	1	01	01	H3931_078_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H3931	078	0	1	01	01	H3931_078_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00
H3931	078	0	1	01	01	H3931_078_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H3949	002	0	1	01	01	H3949_002_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3949	002	0	1	01	01	H3949_002_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H3949	002	0	1	01	01	H3949_002_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H3949	002	0	1	01	01	H3949_002_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H3949	012	0	1	01	01	H3949_012_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3949	012	0	1	01	01	H3949_012_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H3949	012	0	1	01	01	H3949_012_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H3949	012	0	1	01	01	H3949_012_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H3949	013	0	1	01	01	H3949_013_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H3949	013	0	1	01	01	H3949_013_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3949	013	0	1	01	01	H3949_013_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H3949	013	0	1	01	01	H3949_013_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H3949	015	0	1	02	01	H3949_015_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3949	015	0	1	02	01	H3949_015_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H3949	015	0	1	02	01	H3949_015_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H3949	015	0	1	02	01	H3949_015_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H3949	017	0	1	01	01	H3949_017_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3949	017	0	1	01	01	H3949_017_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H3949	017	0	1	01	01	H3949_017_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H3949	017	0	1	01	01	H3949_017_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H3949	020	0	1	01	01	H3949_020_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H3949	020	0	1	01	01	H3949_020_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H3949	020	0	1	01	01	H3949_020_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H3949	020	0	1	01	01	H3949_020_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H3952	018	0	1	01	01	H3952_018_0	5	1	2	1	Generic	010000		2				Generic	110000000010100000000	34									34		34									34	Generic	2	2	Generic																						Generic	0.00									0.00		0.00									0.00
H3952	018	0	1	01	01	H3952_018_0	5	4	2	1	Specialty	110001		1				Specialty	110000000010100000000	34									34		34									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H3952	018	0	1	01	01	H3952_018_0	5	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	110000000010100000000	34									34		34									34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00									75.00		75.00									75.00
H3952	018	0	1	01	01	H3952_018_0	5	2	2	1	Preferred Brand	000001		2				Preferred Brand	110000000010100000000	34									34		34									34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	47.00									47.00		47.00									47.00
H3952	020	0	1	01	01	H3952_020_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H3952	020	0	1	01	01	H3952_020_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H3952	020	0	1	01	01	H3952_020_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3952	020	0	1	01	01	H3952_020_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3952	020	0	1	01	01	H3952_020_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3952	020	0	1	01	01	H3952_020_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00
H3952	020	0	1	01	01	H3952_020_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3952	020	0	1	01	01	H3952_020_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H3952	040	0	1	01	01	H3952_040_0	7	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H3952	040	0	1	01	01	H3952_040_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			40.00								20.00
H3952	040	0	1	01	01	H3952_040_0	7	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H3952	040	0	1	01	01	H3952_040_0	7	4	3	1	Specialty	110001		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3952	043	0	1	01	01	H3952_043_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00
H3952	043	0	1	01	01	H3952_043_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H3952	043	0	1	01	01	H3952_043_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00
H3952	043	0	1	01	01	H3952_043_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H3952	043	0	1	01	01	H3952_043_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00
H3952	043	0	1	01	01	H3952_043_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3952	043	0	1	01	01	H3952_043_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3952	043	0	1	01	01	H3952_043_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H3954	021	0	1	01	01	H3954_021_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	021	0	1	01	01	H3954_021_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	021	0	1	01	01	H3954_021_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	021	0	1	01	01	H3954_021_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	024	0	1	01	01	H3954_024_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	024	0	1	01	01	H3954_024_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	024	0	1	01	01	H3954_024_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	024	0	1	01	01	H3954_024_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	027	0	1	01	01	H3954_027_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	027	0	1	01	01	H3954_027_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	027	0	1	01	01	H3954_027_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	027	0	1	01	01	H3954_027_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	033	0	1	01	01	H3954_033_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	033	0	1	01	01	H3954_033_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	033	0	1	01	01	H3954_033_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	033	0	1	01	01	H3954_033_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	039	0	1	01	01	H3954_039_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	039	0	1	01	01	H3954_039_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	039	0	1	01	01	H3954_039_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	039	0	1	01	01	H3954_039_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	042	0	1	01	01	H3954_042_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	042	0	1	01	01	H3954_042_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	042	0	1	01	01	H3954_042_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	042	0	1	01	01	H3954_042_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	045	0	1	01	01	H3954_045_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	045	0	1	01	01	H3954_045_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	045	0	1	01	01	H3954_045_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	045	0	1	01	01	H3954_045_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	048	0	1	01	01	H3954_048_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	048	0	1	01	01	H3954_048_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	048	0	1	01	01	H3954_048_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	048	0	1	01	01	H3954_048_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	051	0	1	01	01	H3954_051_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	051	0	1	01	01	H3954_051_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	051	0	1	01	01	H3954_051_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	051	0	1	01	01	H3954_051_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	057	0	1	01	01	H3954_057_0	8	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	057	0	1	01	01	H3954_057_0	8	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	057	0	1	01	01	H3954_057_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	057	0	1	01	01	H3954_057_0	8	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	060	0	1	01	01	H3954_060_0	7	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	060	0	1	01	01	H3954_060_0	7	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	060	0	1	01	01	H3954_060_0	7	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	060	0	1	01	01	H3954_060_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	063	0	1	01	01	H3954_063_0	7	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	063	0	1	01	01	H3954_063_0	7	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	063	0	1	01	01	H3954_063_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	063	0	1	01	01	H3954_063_0	7	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	067	0	1	01	01	H3954_067_0	4	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	067	0	1	01	01	H3954_067_0	4	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	067	0	1	01	01	H3954_067_0	4	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	067	0	1	01	01	H3954_067_0	4	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	079	0	1	01	01	H3954_079_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	079	0	1	01	01	H3954_079_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	079	0	1	01	01	H3954_079_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	079	0	1	01	01	H3954_079_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	091	0	1	01	01	H3954_091_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	091	0	1	01	01	H3954_091_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	091	0	1	01	01	H3954_091_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	091	0	1	01	01	H3954_091_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	097	0	1	01	01	H3954_097_0	4	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H3954	097	0	1	01	01	H3954_097_0	4	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	45.00	135.00								45.00			112.50								45.00
H3954	097	0	1	01	01	H3954_097_0	4	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	94.00	282.00								94.00			235.00								94.00
H3954	097	0	1	01	01	H3954_097_0	4	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H3954	100	0	1	01	01	H3954_100_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	100	0	1	01	01	H3954_100_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	100	0	1	01	01	H3954_100_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	100	0	1	01	01	H3954_100_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	106	0	1	01	01	H3954_106_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	106	0	1	01	01	H3954_106_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	106	0	1	01	01	H3954_106_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	106	0	1	01	01	H3954_106_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	109	0	1	01	01	H3954_109_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	109	0	1	01	01	H3954_109_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	109	0	1	01	01	H3954_109_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	109	0	1	01	01	H3954_109_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	112	0	1	01	01	H3954_112_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	112	0	1	01	01	H3954_112_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	112	0	1	01	01	H3954_112_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	112	0	1	01	01	H3954_112_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	115	0	1	01	01	H3954_115_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	115	0	1	01	01	H3954_115_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	115	0	1	01	01	H3954_115_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	115	0	1	01	01	H3954_115_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	121	0	1	01	01	H3954_121_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	121	0	1	01	01	H3954_121_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	121	0	1	01	01	H3954_121_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	121	0	1	01	01	H3954_121_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	124	0	1	01	01	H3954_124_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	124	0	1	01	01	H3954_124_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	124	0	1	01	01	H3954_124_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	124	0	1	01	01	H3954_124_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	127	0	1	01	01	H3954_127_0	2	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	127	0	1	01	01	H3954_127_0	2	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	127	0	1	01	01	H3954_127_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	127	0	1	01	01	H3954_127_0	2	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	130	0	1	01	01	H3954_130_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	130	0	1	01	01	H3954_130_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	130	0	1	01	01	H3954_130_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3954	130	0	1	01	01	H3954_130_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	133	0	1	01	01	H3954_133_0	4	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H3954	133	0	1	01	01	H3954_133_0	4	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H3954	133	0	1	01	01	H3954_133_0	4	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H3954	133	0	1	01	01	H3954_133_0	4	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H3957	003	0	1	01	01	H3957_003_0	9	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	003	0	1	01	01	H3957_003_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00
H3957	003	0	1	01	01	H3957_003_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	003	0	1	01	01	H3957_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00
H3957	006	0	1	01	01	H3957_006_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	006	0	1	01	01	H3957_006_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00
H3957	006	0	1	01	01	H3957_006_0	8	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	006	0	1	01	01	H3957_006_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00
H3957	016	0	1	01	01	H3957_016_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00
H3957	016	0	1	01	01	H3957_016_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00
H3957	016	0	1	01	01	H3957_016_0	8	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	016	0	1	01	01	H3957_016_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	020	0	1	01	01	H3957_020_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3957	020	0	1	01	01	H3957_020_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3957	020	0	1	01	01	H3957_020_0	7	4	4	3	Specialty Drugs	110001	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3957	020	0	1	01	01	H3957_020_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	020	0	1	01	01	H3957_020_0	7	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	020	0	1	01	01	H3957_020_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		162.50	162.50								65.00
H3957	020	0	1	01	01	H3957_020_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3957	020	0	1	01	01	H3957_020_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	021	0	1	01	01	H3957_021_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	021	0	1	01	01	H3957_021_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3957	021	0	1	01	01	H3957_021_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		162.50	162.50								65.00
H3957	021	0	1	01	01	H3957_021_0	7	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	021	0	1	01	01	H3957_021_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	021	0	1	01	01	H3957_021_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3957	021	0	1	01	01	H3957_021_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3957	021	0	1	01	01	H3957_021_0	7	4	4	3	Specialty Drugs	110001	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3957	022	0	1	01	01	H3957_022_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	022	0	1	01	01	H3957_022_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H3957	022	0	1	01	01	H3957_022_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H3957	022	0	1	01	01	H3957_022_0	7	4	4	3	Specialty Drugs	110001	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3957	022	0	1	01	01	H3957_022_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H3957	022	0	1	01	01	H3957_022_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H3957	022	0	1	01	01	H3957_022_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		162.50	162.50								65.00
H3957	022	0	1	01	01	H3957_022_0	7	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	031	0	1	01	01	H3957_031_0	9	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	031	0	1	01	01	H3957_031_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		187.50	187.50								75.00
H3957	031	0	1	01	01	H3957_031_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	2.00	6.00								2.00		5.00	5.00								2.00
H3957	031	0	1	01	01	H3957_031_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	47.00	141.00								47.00		117.50	117.50								47.00
H3957	032	0	1	01	01	H3957_032_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	47.00	141.00								47.00		117.50	117.50								47.00
H3957	032	0	1	01	01	H3957_032_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	2.00	6.00								2.00		5.00	5.00								2.00
H3957	032	0	1	01	01	H3957_032_0	10	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	032	0	1	01	01	H3957_032_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		187.50	187.50								75.00
H3957	033	0	1	01	01	H3957_033_0	10	4	4	1	Specialty Drugs	110001	1	1				Specialty Drugs	111000000010110000000	34	90								34		34								90	34	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H3957	033	0	1	01	01	H3957_033_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		187.50	187.50								75.00
H3957	033	0	1	01	01	H3957_033_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	2.00	6.00								2.00		5.00	5.00								2.00
H3957	033	0	1	01	01	H3957_033_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	47.00	141.00								47.00		117.50	117.50								47.00
H3959	001	0	1	01	01	H3959_001_0	8	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	61.00	183.00								61.00			183.00								61.00
H3959	001	0	1	01	01	H3959_001_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	28.00	56.00								28.00			56.00								28.00
H3959	001	0	1	01	01	H3959_001_0	8	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	001	0	1	01	01	H3959_001_0	8	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	001	0	1	01	01	H3959_001_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	001	0	1	01	01	H3959_001_0	8	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	12.00								6.00			12.00								6.00
H3959	001	0	1	01	01	H3959_001_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	001	0	1	01	01	H3959_001_0	8	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	12.00								6.00			12.00								6.00
H3959	002	0	1	01	01	H3959_002_0	8	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	002	0	1	01	01	H3959_002_0	8	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	002	0	1	01	01	H3959_002_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	002	0	1	01	01	H3959_002_0	8	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	002	0	1	01	01	H3959_002_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	002	0	1	01	01	H3959_002_0	8	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00			201.00								67.00
H3959	002	0	1	01	01	H3959_002_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	33.00	66.00								33.00			66.00								33.00
H3959	002	0	1	01	01	H3959_002_0	8	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	006	0	1	01	01	H3959_006_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H3959	006	0	1	01	01	H3959_006_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	70.00								35.00			70.00								35.00
H3959	006	0	1	01	01	H3959_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	006	0	1	01	01	H3959_006_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	006	0	1	01	01	H3959_006_0	7	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	006	0	1	01	01	H3959_006_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	006	0	1	01	01	H3959_006_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	006	0	1	01	01	H3959_006_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	010	0	1	01	01	H3959_010_0	8	3	3	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100		2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
H3959	010	0	1	01	01	H3959_010_0	8	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	60.00								30.00			60.00								30.00
H3959	010	0	1	01	01	H3959_010_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	12.00								6.00			12.00								6.00
H3959	010	0	1	01	01	H3959_010_0	8	4	3	1	Tier 4 - Specialty Drugs	010010		1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	011	0	1	01	01	H3959_011_0	8	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	61.00	183.00								61.00			183.00								61.00
H3959	011	0	1	01	01	H3959_011_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	70.00								35.00			70.00								35.00
H3959	011	0	1	01	01	H3959_011_0	8	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	011	0	1	01	01	H3959_011_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	011	0	1	01	01	H3959_011_0	8	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	011	0	1	01	01	H3959_011_0	8	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	011	0	1	01	01	H3959_011_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	011	0	1	01	01	H3959_011_0	8	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			10.00								5.00
H3959	023	0	1	01	01	H3959_023_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	14.00								7.00			14.00								7.00
H3959	023	0	1	01	01	H3959_023_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	29.00	58.00								29.00			58.00								29.00
H3959	023	0	1	01	01	H3959_023_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	66.00	198.00								66.00			198.00								66.00
H3959	023	0	1	01	01	H3959_023_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	026	0	1	01	01	H3959_026_0	4	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	110000000010000000000	30									30											31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00									5.00											5.00
H3959	026	0	1	01	01	H3959_026_0	4	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	110000000010000000000	30									30											31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00									32.00											32.00
H3959	026	0	1	01	01	H3959_026_0	4	3	3	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100		2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	110000000010000000000	30									30											31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	63.00									63.00											63.00
H3959	026	0	1	01	01	H3959_026_0	4	4	3	1	Tier 4 - Specialty	010010		1				Tier 4 - Specialty	110000000010000000000	30									30											31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33									33											33	Tier 4 - Specialty																					
H3959	027	0	1	01	01	H3959_027_0	7	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	027	0	1	01	01	H3959_027_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	027	0	1	01	01	H3959_027_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	027	0	1	01	01	H3959_027_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2			Tier 1 - Preferred Generic																							Tier 1 - Preferred Generic			Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic																					
H3959	027	0	1	01	01	H3959_027_0	7	5	4	3	Tier 5 - Other - Special Needs	001001	1	2	1		1	Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	027	0	1	01	01	H3959_027_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	027	0	1	01	01	H3959_027_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00			201.00								67.00
H3959	027	0	1	01	01	H3959_027_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	36.00	72.00								36.00			72.00								36.00
H3959	027	0	1	01	01	H3959_027_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	14.00								7.00			14.00								7.00
H3959	027	0	1	01	01	H3959_027_0	7	5	4	1	Tier 5 - Other - Special Needs	001001	1	2				Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	028	0	1	01	01	H3959_028_0	7	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	028	0	1	01	01	H3959_028_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	028	0	1	01	01	H3959_028_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	028	0	1	01	01	H3959_028_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2			Tier 1 - Preferred Generic																							Tier 1 - Preferred Generic			Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic																					
H3959	028	0	1	01	01	H3959_028_0	7	5	4	1	Tier 5 - Other - Special Needs	001001	1	2				Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	028	0	1	01	01	H3959_028_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	028	0	1	01	01	H3959_028_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00			177.00								59.00
H3959	028	0	1	01	01	H3959_028_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	27.00	54.00								27.00			54.00								27.00
H3959	028	0	1	01	01	H3959_028_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	12.00								6.00			12.00								6.00
H3959	028	0	1	01	01	H3959_028_0	7	5	4	3	Tier 5 - Other - Special Needs	001001	1	2	1		1	Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	029	0	1	01	01	H3959_029_0	6	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	14.00								7.00			14.00								7.00
H3959	029	0	1	01	01	H3959_029_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	31.00	62.00								31.00			62.00								31.00
H3959	029	0	1	01	01	H3959_029_0	6	5	4	3	Tier 5 - Other - Special Needs	001001	1	2	1		1	Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	029	0	1	01	01	H3959_029_0	6	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	029	0	1	01	01	H3959_029_0	6	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	029	0	1	01	01	H3959_029_0	6	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	029	0	1	01	01	H3959_029_0	6	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2			Tier 1 - Preferred Generic																							Tier 1 - Preferred Generic			Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic																					
H3959	029	0	1	01	01	H3959_029_0	6	5	4	1	Tier 5 - Other - Special Needs	001001	1	2				Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	029	0	1	01	01	H3959_029_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	029	0	1	01	01	H3959_029_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00			201.00								67.00
H3959	030	0	1	01	01	H3959_030_0	6	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	12.00								6.00			12.00								6.00
H3959	030	0	1	01	01	H3959_030_0	6	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H3959	030	0	1	01	01	H3959_030_0	6	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H3959	030	0	1	01	01	H3959_030_0	6	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H3959	030	0	1	01	01	H3959_030_0	6	5	4	3	Tier 5 - Other - Special Needs	001001	1	2	1		1	Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	030	0	1	01	01	H3959_030_0	6	5	4	1	Tier 5 - Other - Special Needs	001001	1	2				Tier 5 - Other - Special Needs	111000000010010000000	30	90								30										90	31	Tier 5 - Other - Special Needs	2	2	Tier 5 - Other - Special Needs																						Tier 5 - Other - Special Needs	0.00	0.00								0.00			0.00								0.00
H3959	030	0	1	01	01	H3959_030_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H3959	030	0	1	01	01	H3959_030_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00			186.00								62.00
H3959	030	0	1	01	01	H3959_030_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	27.00	54.00								27.00			54.00								27.00
H3959	030	0	1	01	01	H3959_030_0	6	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2			Tier 1 - Preferred Generic																							Tier 1 - Preferred Generic			Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic																					
H3962	001	0	1	01	01	H3962_001_0	9	3	4	1	Non-Preferred Brand Drugs	100000	3	2				Non-Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Non-Preferred Brand Drugs	1	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	85.00	210.00								85.00			210.00								85.00
H3962	001	0	1	01	01	H3962_001_0	9	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Preferred Brand Drugs	1	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	85.00								35.00			85.00								35.00
H3962	001	0	1	01	01	H3962_001_0	9	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3962	001	0	1	01	01	H3962_001_0	9	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3962	001	0	1	01	01	H3962_001_0	9	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3962	001	0	1	01	01	H3962_001_0	9	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H3962	001	0	1	01	01	H3962_001_0	9	3	4	3	Non-Preferred Brand Drugs	100000	3	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H3962	001	0	1	01	01	H3962_001_0	9	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3962	004	0	1	01	01	H3962_004_0	9	3	4	1	Non-Preferred Brand Drugs	100000	3	2				Non-Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Non-Preferred Brand Drugs	1	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	85.00	210.00								85.00			210.00								85.00
H3962	004	0	1	01	01	H3962_004_0	9	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Preferred Brand Drugs	1	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	85.00								35.00			85.00								35.00
H3962	004	0	1	01	01	H3962_004_0	9	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3962	004	0	1	01	01	H3962_004_0	9	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3962	004	0	1	01	01	H3962_004_0	9	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H3962	004	0	1	01	01	H3962_004_0	9	3	4	3	Non-Preferred Brand Drugs	100000	3	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H3962	004	0	1	01	01	H3962_004_0	9	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H3962	004	0	1	01	01	H3962_004_0	9	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
H3962	007	0	1	01	01	H3962_007_0	9	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	9.00	25.00								9.00			25.00								9.00
H3962	007	0	1	01	01	H3962_007_0	9	2	4	1	Formulary Brand Drugs	000010	1	2				Formulary Brand Drugs	111000000010010000000	34	90								34										90	34	Formulary Brand Drugs	1	2	Formulary Brand Drugs																						Formulary Brand Drugs	40.00	100.00								40.00			100.00								40.00
H3962	007	0	1	01	01	H3962_007_0	9	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
H3964	002	0	1	01	01	H3964_002_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	110000000010000000000	31									31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00									45.00											45.00
H3964	002	0	1	01	01	H3964_002_0	2	1	4	1	Generic	010000	1	2				Generic	110000000010000000000	31									31											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H3964	003	0	1	01	01	H3964_003_0	3	2	3	1	Preferred Brand	010011		2				Preferred Brand	110000000010000000000	31									31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00									35.00											35.00
H3964	003	0	1	01	01	H3964_003_0	3	1	3	1	Generic	010000		2				Generic	110000000010000000000	31									31											31	Generic	2	2	Generic																						Generic	5.00									5.00											5.00
H3964	003	0	1	01	01	H3964_003_0	3	3	3	1	Specialty	010010		1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	28									28											28	Specialty																					
H4003	001	0	1	01	01	H4003_001_0	3	4	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4003	001	0	1	01	01	H4003_001_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4003	001	0	1	01	01	H4003_001_0	3	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4003	001	0	1	01	01	H4003_001_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4003	001	0	1	01	01	H4003_001_0	3	4	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4003	001	0	1	01	01	H4003_001_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4003	001	0	1	01	01	H4003_001_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4003	001	0	1	01	01	H4003_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
H4003	009	0	1	01	01	H4003_009_0	4	3	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4003	009	0	1	01	01	H4003_009_0	4	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4003	009	0	1	01	01	H4003_009_0	4	1	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4003	009	0	1	01	01	H4003_009_0	4	3	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4003	009	0	1	01	01	H4003_009_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4003	009	0	1	01	01	H4003_009_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4003	015	0	1	01	01	H4003_015_0	5	3	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4003	015	0	1	01	01	H4003_015_0	5	3	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4003	015	0	1	01	01	H4003_015_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4003	015	0	1	01	01	H4003_015_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4003	015	0	1	01	01	H4003_015_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4003	015	0	1	01	01	H4003_015_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	015	0	1	01	01	H4004_015_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	015	0	1	01	01	H4004_015_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4004	015	0	1	01	01	H4004_015_0	3	4	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4004	015	0	1	01	01	H4004_015_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	015	0	1	01	01	H4004_015_0	3	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4004	015	0	1	01	01	H4004_015_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4004	015	0	1	01	01	H4004_015_0	3	4	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4004	015	0	1	01	01	H4004_015_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
H4004	035	0	1	01	01	H4004_035_0	3	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4004	035	0	1	01	01	H4004_035_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	035	0	1	01	01	H4004_035_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4004	035	0	1	01	01	H4004_035_0	3	3	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4004	035	0	1	01	01	H4004_035_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	035	0	1	01	01	H4004_035_0	3	3	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4004	049	0	1	01	01	H4004_049_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4004	049	0	1	01	01	H4004_049_0	5	3	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4004	049	0	1	01	01	H4004_049_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4004	049	0	1	01	01	H4004_049_0	5	3	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H4004	049	0	1	01	01	H4004_049_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
H4004	049	0	1	01	01	H4004_049_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4005	003	0	1	04	01	H4005_003_0	7	1	4	3	Tier 1/Nivel 1	010000	1	2	1		1	Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
H4005	003	0	1	04	01	H4005_003_0	7	2	4	3	Tier 2/Nivel 2	000001	1	2	2			Tier 2/Nivel 2																							Tier 2/Nivel 2			Tier 2/Nivel 2																						Tier 2/Nivel 2																					
H4005	003	0	1	04	01	H4005_003_0	7	3	4	3	Tier 3/ Nivel 3	000010	1	2	2			Tier 3/ Nivel 3																							Tier 3/ Nivel 3			Tier 3/ Nivel 3																						Tier 3/ Nivel 3																					
H4005	003	0	1	04	01	H4005_003_0	7	4	4	3	Tier 4/ Nivel 4	100000	1	2	2			Tier 4/ Nivel 4																							Tier 4/ Nivel 4			Tier 4/ Nivel 4																						Tier 4/ Nivel 4																					
H4005	003	0	1	04	01	H4005_003_0	7	5	4	1	Tier 5/ Nivel 5	010010	1	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
H4005	003	0	1	04	01	H4005_003_0	7	1	4	1	Tier 1/Nivel 1	010000	1	2				Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
H4005	003	0	1	04	01	H4005_003_0	7	2	4	1	Tier 2/Nivel 2	000001	1	2				Tier 2/Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/Nivel 2	1	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	10.00	30.00	10.00							10.00			30.00								10.00
H4005	003	0	1	04	01	H4005_003_0	7	3	4	1	Tier 3/ Nivel 3	000010	1	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	15.00	45.00	15.00							15.00			45.00								15.00
H4005	003	0	1	04	01	H4005_003_0	7	4	4	1	Tier 4/ Nivel 4	100000	1	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	3	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	45.00	135.00	45.00							45.00			135.00								45.00
H4005	003	0	1	04	01	H4005_003_0	7	5	4	3	Tier 5/ Nivel 5	010010	1	1	2			Tier 5/ Nivel 5																							Tier 5/ Nivel 5			Tier 5/ Nivel 5																						Tier 5/ Nivel 5																					
H4005	004	0	1	04	01	H4005_004_0	6	4	4	3	Tier 4/ Nivel 4	100000	1	2	2			Tier 4/ Nivel 4																							Tier 4/ Nivel 4			Tier 4/ Nivel 4																						Tier 4/ Nivel 4																					
H4005	004	0	1	04	01	H4005_004_0	6	3	4	3	Tier 3/ Nivel 3	000010	1	2	2			Tier 3/ Nivel 3																							Tier 3/ Nivel 3			Tier 3/ Nivel 3																						Tier 3/ Nivel 3																					
H4005	004	0	1	04	01	H4005_004_0	6	2	4	3	Tier 2/Nivel 2	000001	1	2	2			Tier 2/Nivel 2																							Tier 2/Nivel 2			Tier 2/Nivel 2																						Tier 2/Nivel 2																					
H4005	004	0	1	04	01	H4005_004_0	6	1	4	3	Tier 1/Nivel 1	010000	1	2	1		1	Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
H4005	004	0	1	04	01	H4005_004_0	6	5	4	1	Tier 5/ Nivel 5	010010	1	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
H4005	004	0	1	04	01	H4005_004_0	6	1	4	1	Tier 1/Nivel 1	010000	1	2				Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
H4005	004	0	1	04	01	H4005_004_0	6	2	4	1	Tier 2/Nivel 2	000001	1	2				Tier 2/Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/Nivel 2	1	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	25.00	75.00	25.00							25.00			75.00								25.00
H4005	004	0	1	04	01	H4005_004_0	6	5	4	3	Tier 5/ Nivel 5	010010	1	1	2			Tier 5/ Nivel 5																							Tier 5/ Nivel 5			Tier 5/ Nivel 5																						Tier 5/ Nivel 5																					
H4005	004	0	1	04	01	H4005_004_0	6	4	4	1	Tier 4/ Nivel 4	100000	1	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	3	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	45.00	135.00	45.00							45.00			135.00								45.00
H4005	004	0	1	04	01	H4005_004_0	6	3	4	1	Tier 3/ Nivel 3	000010	1	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	45.00	135.00	45.00							45.00			135.00								45.00
H4006	007	0	1	01	01	H4006_007_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4006	007	0	1	01	01	H4006_007_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4006	007	0	1	01	01	H4006_007_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4006	007	0	1	01	01	H4006_007_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H4006	007	0	1	01	01	H4006_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00
H4006	007	0	1	01	01	H4006_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H4006	007	0	1	01	01	H4006_007_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	007	0	1	01	01	H4006_007_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H4006	008	0	1	02	01	H4006_008_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00
H4006	008	0	1	02	01	H4006_008_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	18.00	54.00								18.00		18.00	36.00								18.00
H4006	008	0	1	02	01	H4006_008_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4006	008	0	1	02	01	H4006_008_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4006	008	0	1	02	01	H4006_008_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4006	008	0	1	02	01	H4006_008_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00
H4006	008	0	1	02	01	H4006_008_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	008	0	1	02	01	H4006_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	36.00	108.00								36.00		36.00	72.00								36.00
H4006	013	0	1	01	01	H4006_013_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4006	013	0	1	01	01	H4006_013_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H4006	013	0	1	01	01	H4006_013_0	7	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	013	0	1	01	01	H4006_013_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4006	015	0	1	01	01	H4006_015_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4006	015	0	1	01	01	H4006_015_0	7	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	015	0	1	01	01	H4006_015_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4006	015	0	1	01	01	H4006_015_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H4006	018	0	1	01	01	H4006_018_0	7	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	018	0	1	01	01	H4006_018_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4006	018	0	1	01	01	H4006_018_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4006	018	0	1	01	01	H4006_018_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H4006	020	0	1	01	01	H4006_020_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00
H4006	020	0	1	01	01	H4006_020_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H4006	020	0	1	01	01	H4006_020_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4006	020	0	1	01	01	H4006_020_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00
H4006	020	0	1	01	01	H4006_020_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	020	0	1	01	01	H4006_020_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H4006	020	0	1	01	01	H4006_020_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4006	020	0	1	01	01	H4006_020_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4006	022	0	1	01	01	H4006_022_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H4006	022	0	1	01	01	H4006_022_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
H4006	022	0	1	01	01	H4006_022_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4006	022	0	1	01	01	H4006_022_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H4007	002	0	1	01	01	H4007_002_0	3	1	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010110000000	30	90								30		30								90	34	Generic	2	1	Generic	25	25								25		25	25								25	Generic																					
H4007	002	0	1	01	01	H4007_002_0	3	2	4	3	Brand	000010	1	2	1	10000000	2	Brand	111000000010110000000	30	90								30		30								90	34	Brand	2	1	Brand	25	25								25		25	25								25	Brand																					
H4007	002	0	1	01	01	H4007_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25		25	25								25	Non-Preferred Brand																					
H4007	005	0	1	01	01	H4007_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25		25	25								25	Non-Preferred Brand																					
H4007	005	0	1	01	01	H4007_005_0	3	1	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010110000000	30	90								30		30								90	34	Generic	2	1	Generic	25	25								25		25	25								25	Generic																					
H4007	005	0	1	01	01	H4007_005_0	3	2	4	3	Brand	000010	1	2	1	10000000	2	Brand	111000000010110000000	30	90								30		30								90	34	Brand	2	1	Brand	25	25								25		25	25								25	Brand																					
H4007	008	0	1	01	01	H4007_008_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H4007	008	0	1	01	01	H4007_008_0	4	2	4	3	Brand	000010	1	2	1	10000000	2	Brand	111000000010000110110	30	90								30				30	90		30	90			34	Brand	2	2	Brand																						Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H4007	008	0	1	01	01	H4007_008_0	4	1	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010000110110	30	90								30				30	90		30	90			34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4007	008	0	1	01	01	H4007_008_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H4007	008	0	1	01	01	H4007_008_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010000110110	30	90								30				30	90		30	90			34	Brand	2	2	Brand																						Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H4007	008	0	1	01	01	H4007_008_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000110110	30	90								30				30	90		30	90			34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4007	010	0	1	01	01	H4007_010_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H4007	010	0	1	01	01	H4007_010_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4007	010	0	1	01	01	H4007_010_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H4007	010	0	1	01	01	H4007_010_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4007	010	0	1	01	01	H4007_010_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4007	010	0	1	01	01	H4007_010_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00
H4007	010	0	1	01	01	H4007_010_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4007	010	0	1	01	01	H4007_010_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00
H4007	012	0	1	01	01	H4007_012_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	34	Brand	2	2	Brand																						Brand	20.00	60.00								20.00		20.00	50.00								20.00
H4007	012	0	1	01	01	H4007_012_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H4007	012	0	1	01	01	H4007_012_0	3	1	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010110000000	30	90								30		30								90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4007	012	0	1	01	01	H4007_012_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4007	012	0	1	01	01	H4007_012_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010110000000	30	90								30		30								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H4007	012	0	1	01	01	H4007_012_0	3	2	4	3	Brand	000010	1	2	1	10000000	2	Brand	111000000010110000000	30	90								30		30								90	34	Brand	2	2	Brand																						Brand	20.00	60.00								20.00		20.00	50.00								20.00
H4008	001	0	1	09	04	H4008_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4008	001	0	1	09	04	H4008_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H4008	001	0	1	09	04	H4008_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4008	001	0	1	09	04	H4008_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4008	001	0	1	09	04	H4008_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4008	001	0	1	09	04	H4008_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H4008	001	0	1	09	04	H4008_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4008	001	0	1	09	04	H4008_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4011	003	0	1	04	01	H4011_003_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H4011	003	0	1	04	01	H4011_003_0	9	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
H4011	003	0	1	04	01	H4011_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H4011	003	0	1	04	01	H4011_003_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
H4011	004	0	1	04	01	H4011_004_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H4011	004	0	1	04	01	H4011_004_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00											15.00
H4011	004	0	1	04	01	H4011_004_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H4011	004	0	1	04	01	H4011_004_0	9	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
H4011	004	0	1	04	01	H4011_004_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H4011	004	0	1	04	01	H4011_004_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4011	004	0	1	04	01	H4011_004_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4011	004	0	1	04	01	H4011_004_0	9	4	4	3	Specialty Tier Brand	010011	1	1	2			Specialty Tier Brand																							Specialty Tier Brand			Specialty Tier Brand																						Specialty Tier Brand																					
H4012	003	0	1	01	01	H4012_003_0	7	3	4	3	Tier 3/ Nivel 3	000010	3	2	1		1	Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	1	Tier 3/ Nivel 3	70	70	70							70			70								70	Tier 3/ Nivel 3																					
H4012	003	0	1	01	01	H4012_003_0	7	4	4	1	Tier 4/ Nivel 4	100000	3	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	4	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	10.00	30.00	10.00							10.00			30.00								10.00
H4012	003	0	1	01	01	H4012_003_0	7	3	4	1	Tier 3/ Nivel 3	000010	3	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	1.00	3.00	1.00							1.00			3.00								1.00
H4012	003	0	1	01	01	H4012_003_0	7	2	4	1	Tier 2/ Nivel 2	000001	3	2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	1	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	.50	1.50	.50							.50			1.50								.50
H4012	003	0	1	01	01	H4012_003_0	7	1	4	1	Tier 1/ Nivel 1	010000	3	2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00
H4012	003	0	1	01	01	H4012_003_0	7	5	4	3	Tier 5/ Nivel 5	010010	3	1	1		1	Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	70	70	70							70			70								70	Tier 5/ Nivel 5																					
H4012	003	0	1	01	01	H4012_003_0	7	4	4	3	Tier 4/ Nivel 4	100000	3	2	1		1	Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	1	Tier 4/ Nivel 4	70	70	70							70			70								70	Tier 4/ Nivel 4																					
H4012	003	0	1	01	01	H4012_003_0	7	5	4	1	Tier 5/ Nivel 5	010010	3	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
H4012	003	0	1	01	01	H4012_003_0	7	2	4	3	Tier 2/ Nivel 2	000001	3	2	1		1	Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	1	1	Tier 2/ Nivel 2	70	70	70							70			70								70	Tier 2/ Nivel 2																					
H4012	003	0	1	01	01	H4012_003_0	7	1	4	3	Tier 1/ Nivel 1	010000	3	2	1		1	Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	1	Tier 1/ Nivel 1	70	70	70							70			70								70	Tier 1/ Nivel 1																					
H4012	004	0	1	01	01	H4012_004_0	6	1	4	1	Tier 1/ Nivel 1	010000	3	2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	2	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00
H4012	004	0	1	01	01	H4012_004_0	6	2	4	1	Tier 2/ Nivel 2	000001	3	2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	2	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	.50	1.50	.50							.50			1.50								.50
H4012	004	0	1	01	01	H4012_004_0	6	3	4	1	Tier 3/ Nivel 3	000010	3	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	2	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	1.00	3.00	1.00							1.00			3.00								1.00
H4012	004	0	1	01	01	H4012_004_0	6	4	4	1	Tier 4/ Nivel 4	100000	3	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	2	4	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	10.00	30.00	10.00							10.00			30.00								10.00
H4012	004	0	1	01	01	H4012_004_0	6	5	4	1	Tier 5/ Nivel 5	010010	3	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
H4012	005	0	1	01	01	H4012_005_0	7	4	4	3	Tier 4/ Nivel 4	100000	3	2	1		1	Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	2	1	Tier 4/ Nivel 4	75	75	75							75			75								75	Tier 4/ Nivel 4																					
H4012	005	0	1	01	01	H4012_005_0	7	5	4	3	Tier 5/ Nivel 5	010010	3	1	1		1	Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	75	75	75							75			75								75	Tier 5/ Nivel 5																					
H4012	005	0	1	01	01	H4012_005_0	7	3	4	3	Tier 3/ Nivel 3	000010	3	2	1		1	Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	2	1	Tier 3/ Nivel 3	75	75	75							75			75								75	Tier 3/ Nivel 3																					
H4012	005	0	1	01	01	H4012_005_0	7	2	4	3	Tier 2/ Nivel 2	000001	3	2	1		1	Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	2	1	Tier 2/ Nivel 2	75	75	75							75			75								75	Tier 2/ Nivel 2																					
H4012	005	0	1	01	01	H4012_005_0	7	1	4	3	Tier 1/ Nivel 1	010000	3	2	1		1	Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	2	1	Tier 1/ Nivel 1	75	75	75							75			75								75	Tier 1/ Nivel 1																					
H4012	005	0	1	01	01	H4012_005_0	7	5	4	1	Tier 5/ Nivel 5	010010	3	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
H4012	005	0	1	01	01	H4012_005_0	7	4	4	1	Tier 4/ Nivel 4	100000	3	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	2	2	Tier 4/ Nivel 4																						Tier 4/ Nivel 4	0.50	1.50	0.50							0.50			1.50								0.50
H4012	005	0	1	01	01	H4012_005_0	7	3	4	1	Tier 3/ Nivel 3	000010	3	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	2	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	0.50	1.50	0.50							0.50			1.50								0.50
H4012	005	0	1	01	01	H4012_005_0	7	2	4	1	Tier 2/ Nivel 2	000001	3	2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	2	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	0.50	1.50	0.50							0.50			1.50								0.50
H4012	005	0	1	01	01	H4012_005_0	7	1	4	1	Tier 1/ Nivel 1	010000	3	2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	2	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00
H4036	001	0	1	04	01	H4036_001_0	10	1	4	1	Tier 1 Preferred Generics	001000	3	2				Tier 1 Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H4036	001	0	1	04	01	H4036_001_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H4036	001	0	1	04	01	H4036_001_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H4036	001	0	1	04	01	H4036_001_0	10	4	4	1	Tier 4 Non- Specialty Injectable	010010	1	2				Tier 4 Non- Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non- Specialty Injectable	2	1	Tier 4 Non- Specialty Injectable	33	33								33						33			33		33	Tier 4 Non- Specialty Injectable																					
H4036	001	0	1	04	01	H4036_001_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H4036	001	0	1	04	01	H4036_001_0	10	1	4	3	Tier 1 Preferred Generics	001000	3	2	1		1	Tier 1 Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H4036	001	0	1	04	01	H4036_001_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H4036	001	0	1	04	01	H4036_001_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H4036	001	0	1	04	01	H4036_001_0	10	4	4	3	Tier 4 Non- Specialty Injectable	010010	1	2	2			Tier 4 Non- Specialty Injectable																							Tier 4 Non- Specialty Injectable			Tier 4 Non- Specialty Injectable																						Tier 4 Non- Specialty Injectable																					
H4036	001	0	1	04	01	H4036_001_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H4102	001	0	1	01	01	H4102_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4102	001	0	1	01	01	H4102_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4102	001	0	1	01	01	H4102_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4102	001	0	1	01	01	H4102_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4106	002	0	1	01	01	H4106_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4106	002	0	1	01	01	H4106_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4106	002	0	1	01	01	H4106_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4106	002	0	1	01	01	H4106_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4125	001	0	1	01	01	H4125_001_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H4125	001	0	1	01	01	H4125_001_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H4125	001	0	1	01	01	H4125_001_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H4125	001	0	1	01	01	H4125_001_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H4125	001	0	1	01	01	H4125_001_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H4125	001	0	1	01	01	H4125_001_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H4125	001	0	1	01	01	H4125_001_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H4125	001	0	1	01	01	H4125_001_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4125	002	0	1	01	01	H4125_002_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H4125	002	0	1	01	01	H4125_002_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H4125	002	0	1	01	01	H4125_002_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4125	002	0	1	01	01	H4125_002_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H4125	002	0	1	01	01	H4125_002_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H4125	002	0	1	01	01	H4125_002_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H4125	002	0	1	01	01	H4125_002_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H4125	002	0	1	01	01	H4125_002_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H4125	003	0	1	01	01	H4125_003_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H4125	003	0	1	01	01	H4125_003_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4125	003	0	1	01	01	H4125_003_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4125	003	0	1	01	01	H4125_003_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4125	003	0	1	01	01	H4125_003_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H4125	003	0	1	01	01	H4125_003_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H4125	003	0	1	01	01	H4125_003_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H4125	003	0	1	01	01	H4125_003_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H4152	005	0	1	01	01	H4152_005_0	6	4	4	1	Tier 4	010010	1	2				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4152	005	0	1	01	01	H4152_005_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H4152	005	0	1	01	01	H4152_005_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00
H4152	005	0	1	01	01	H4152_005_0	6	5	4	1	Tier 5	010010	1	1				Tier 5	111000000010010000000	30	90								30										90	31	Tier 5	2	1	Tier 5	33	33								33			33								33	Tier 5																					
H4152	005	0	1	01	01	H4152_005_0	6	3	4	1	Tier  3	100100	1	2				Tier  3	111000000010010000000	30	90								30										90	31	Tier  3	2	2	Tier  3																						Tier  3	65.00	195.00								65.00			162.50								65.00
H4152	007	0	1	02	01	H4152_007_0	6	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H4152	007	0	1	02	01	H4152_007_0	6	5	4	1	Tier 5	010010	1	1				Tier 5	111000000010010000000	30	90								30										90	31	Tier 5	2	1	Tier 5	33	33								33			33								33	Tier 5																					
H4152	007	0	1	02	01	H4152_007_0	6	4	4	1	Tier 4	010010	1	2				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4152	007	0	1	02	01	H4152_007_0	6	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	65.00	195.00								65.00			162.50								65.00
H4152	007	0	1	02	01	H4152_007_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H4152	007	0	1	02	01	H4152_007_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00
H4152	007	0	1	02	01	H4152_007_0	6	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H4152	007	0	1	02	01	H4152_007_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H4152	007	0	1	02	01	H4152_007_0	6	4	4	3	Tier 4	010010	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H4152	007	0	1	02	01	H4152_007_0	6	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			24.00								8.00
H4152	013	0	1	01	01	H4152_013_0	6	4	4	1	Tier 4	010010	1	2				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4152	013	0	1	01	01	H4152_013_0	6	1	4	1	Tier 1	001000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00
H4152	013	0	1	01	01	H4152_013_0	6	5	4	1	Tier 5	010010	1	1				Tier 5	111000000010010000000	30	90								30										90	31	Tier 5	2	1	Tier 5	33	33								33			33								33	Tier 5																					
H4152	013	0	1	01	01	H4152_013_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H4152	013	0	1	01	01	H4152_013_0	6	3	4	1	Tier  3	100100	1	2				Tier  3	111000000010010000000	30	90								30										90	31	Tier  3	2	2	Tier  3																						Tier  3	70.00	210.00								70.00			175.00								70.00
H4204	030	0	1	09	04	H4204_030_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	20.00								8.00			16.00								8.00
H4204	030	0	1	09	04	H4204_030_0	5	3	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	84.00	210.00								84.00			168.00								84.00
H4204	030	0	1	09	04	H4204_030_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	73.00								29.00			58.00								29.00
H4204	030	0	1	09	04	H4204_030_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4204	030	0	1	09	04	H4204_030_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	20.00								8.00			16.00								8.00
H4204	030	0	1	09	04	H4204_030_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4204	030	0	1	09	04	H4204_030_0	5	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4204	030	0	1	09	04	H4204_030_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4204	031	0	1	09	04	H4204_031_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	73.00								29.00			58.00								29.00
H4204	031	0	1	09	04	H4204_031_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	20.00								8.00			16.00								8.00
H4204	031	0	1	09	04	H4204_031_0	5	3	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	84.00	210.00								84.00			168.00								84.00
H4204	031	0	1	09	04	H4204_031_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4204	031	0	1	09	04	H4204_031_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	20.00								8.00			16.00								8.00
H4204	031	0	1	09	04	H4204_031_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4204	031	0	1	09	04	H4204_031_0	5	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4204	031	0	1	09	04	H4204_031_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4205	005	0	1	09	04	H4205_005_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4205	005	0	1	09	04	H4205_005_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	41.00	123.00								41.00			82.00								41.00
H4205	005	0	1	09	04	H4205_005_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4205	006	0	1	09	04	H4205_006_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	41.00	123.00								41.00			82.00								41.00
H4205	006	0	1	09	04	H4205_006_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4205	006	0	1	09	04	H4205_006_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4205	007	0	1	09	04	H4205_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H4205	007	0	1	09	04	H4205_007_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4205	007	0	1	09	04	H4205_007_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	34	90								34										90	34	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00								60.00			120.00								60.00
H4205	007	0	1	09	04	H4205_007_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4205	008	0	1	09	04	H4205_008_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	34	90								34										90	34	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00								60.00			120.00								60.00
H4205	008	0	1	09	04	H4205_008_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4205	008	0	1	09	04	H4205_008_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H4205	008	0	1	09	04	H4205_008_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H4209	001	0	1	04	01	H4209_001_0	5	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4209	001	0	1	04	01	H4209_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	001	0	1	04	01	H4209_001_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	41.00	123.00								41.00			82.00								41.00
H4209	003	0	1	04	01	H4209_003_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	003	0	1	04	01	H4209_003_0	5	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4209	003	0	1	04	01	H4209_003_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	41.00	123.00								41.00			82.00								41.00
H4209	004	0	1	04	01	H4209_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4209	004	0	1	04	01	H4209_004_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4209	004	0	1	04	01	H4209_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4209	004	0	1	04	01	H4209_004_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4209	004	0	1	04	01	H4209_004_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	004	0	1	04	01	H4209_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H4209	004	0	1	04	01	H4209_004_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	004	0	1	04	01	H4209_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00
H4209	006	0	1	04	01	H4209_006_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	006	0	1	04	01	H4209_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00
H4209	006	0	1	04	01	H4209_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00
H4209	006	0	1	04	01	H4209_006_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4209	006	0	1	04	01	H4209_006_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4209	006	0	1	04	01	H4209_006_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4209	006	0	1	04	01	H4209_006_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4209	006	0	1	04	01	H4209_006_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4270	002	0	1	02	01	H4270_002_0	5	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H4270	002	0	1	02	01	H4270_002_0	5	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H4270	002	0	1	02	01	H4270_002_0	5	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H4270	002	0	1	02	01	H4270_002_0	5	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H4270	002	0	1	02	01	H4270_002_0	5	3	4	3	Tier 3	000010	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H4270	002	0	1	02	01	H4270_002_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H4270	002	0	1	02	01	H4270_002_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H4270	002	0	1	02	01	H4270_002_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H4270	003	0	1	02	01	H4270_003_0	5	3	4	1	Tier 3	000010	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H4270	003	0	1	02	01	H4270_003_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			60.00								30.00
H4270	003	0	1	02	01	H4270_003_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00								8.00			16.00								8.00
H4270	003	0	1	02	01	H4270_003_0	5	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H4362	001	0	1	04	01	H4362_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H4362	001	0	1	04	01	H4362_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H4362	001	0	1	04	01	H4362_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H4362	001	0	1	04	01	H4362_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H4362	001	0	1	04	01	H4362_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H4362	002	0	1	04	01	H4362_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4362	002	0	1	04	01	H4362_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H4362	002	0	1	04	01	H4362_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4362	002	0	1	04	01	H4362_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4362	002	0	1	04	01	H4362_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H4362	002	0	1	04	01	H4362_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H4362	002	0	1	04	01	H4362_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4362	002	0	1	04	01	H4362_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4362	002	0	1	04	01	H4362_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H4362	002	0	1	04	01	H4362_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H4406	001	0	1	02	01	H4406_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4406	001	0	1	02	01	H4406_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
H4406	001	0	1	02	01	H4406_001_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4406	001	0	1	02	01	H4406_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4407	001	0	1	01	01	H4407_001_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	001	0	1	01	01	H4407_001_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	001	0	1	01	01	H4407_001_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	001	0	1	01	01	H4407_001_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	001	0	1	01	01	H4407_001_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	001	0	1	01	01	H4407_001_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	001	0	1	01	01	H4407_001_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4407	001	0	1	01	01	H4407_001_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	001	0	1	01	01	H4407_001_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	001	0	1	01	01	H4407_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	002	0	1	01	01	H4407_002_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	002	0	1	01	01	H4407_002_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	002	0	1	01	01	H4407_002_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	002	0	1	01	01	H4407_002_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	002	0	1	01	01	H4407_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	002	0	1	01	01	H4407_002_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	002	0	1	01	01	H4407_002_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4407	002	0	1	01	01	H4407_002_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	002	0	1	01	01	H4407_002_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	002	0	1	01	01	H4407_002_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	007	0	1	01	01	H4407_007_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	007	0	1	01	01	H4407_007_0	4	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	007	0	1	01	01	H4407_007_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	007	0	1	01	01	H4407_007_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4407	007	0	1	01	01	H4407_007_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	007	0	1	01	01	H4407_007_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	007	0	1	01	01	H4407_007_0	4	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	007	0	1	01	01	H4407_007_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	007	0	1	01	01	H4407_007_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	007	0	1	01	01	H4407_007_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	009	0	1	01	01	H4407_009_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	009	0	1	01	01	H4407_009_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	009	0	1	01	01	H4407_009_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	009	0	1	01	01	H4407_009_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	009	0	1	01	01	H4407_009_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	009	0	1	01	01	H4407_009_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4407	009	0	1	01	01	H4407_009_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	009	0	1	01	01	H4407_009_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	009	0	1	01	01	H4407_009_0	5	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	009	0	1	01	01	H4407_009_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	012	0	1	01	01	H4407_012_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	012	0	1	01	01	H4407_012_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4407	012	0	1	01	01	H4407_012_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	012	0	1	01	01	H4407_012_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	012	0	1	01	01	H4407_012_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	012	0	1	01	01	H4407_012_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	012	0	1	01	01	H4407_012_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	012	0	1	01	01	H4407_012_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	012	0	1	01	01	H4407_012_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	012	0	1	01	01	H4407_012_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	013	0	1	01	01	H4407_013_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	013	0	1	01	01	H4407_013_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4407	013	0	1	01	01	H4407_013_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	013	0	1	01	01	H4407_013_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	013	0	1	01	01	H4407_013_0	4	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	013	0	1	01	01	H4407_013_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	013	0	1	01	01	H4407_013_0	4	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	013	0	1	01	01	H4407_013_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	013	0	1	01	01	H4407_013_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	013	0	1	01	01	H4407_013_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	018	0	1	01	01	H4407_018_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	018	0	1	01	01	H4407_018_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	018	0	1	01	01	H4407_018_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	018	0	1	01	01	H4407_018_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	018	0	1	01	01	H4407_018_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	018	0	1	01	01	H4407_018_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	018	0	1	01	01	H4407_018_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	018	0	1	01	01	H4407_018_0	5	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	018	0	1	01	01	H4407_018_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	018	0	1	01	01	H4407_018_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4407	019	0	1	01	01	H4407_019_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	019	0	1	01	01	H4407_019_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4407	019	0	1	01	01	H4407_019_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4407	019	0	1	01	01	H4407_019_0	6	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	019	0	1	01	01	H4407_019_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	019	0	1	01	01	H4407_019_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	019	0	1	01	01	H4407_019_0	6	2	4	1	Generic	010010	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	019	0	1	01	01	H4407_019_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	019	0	1	01	01	H4407_019_0	6	2	4	3	Generic	010010	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4407	019	0	1	01	01	H4407_019_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4407	020	0	1	01	01	H4407_020_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4407	020	0	1	01	01	H4407_020_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4407	020	0	1	01	01	H4407_020_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4407	020	0	1	01	01	H4407_020_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4407	020	0	1	01	01	H4407_020_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4407	020	0	1	01	01	H4407_020_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4407	020	0	1	01	01	H4407_020_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4407	020	0	1	01	01	H4407_020_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4407	020	0	1	01	01	H4407_020_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4407	020	0	1	01	01	H4407_020_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H4408	001	0	1	04	01	H4408_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	001	0	1	04	01	H4408_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	001	0	1	04	01	H4408_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	001	0	1	04	01	H4408_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	001	0	1	04	01	H4408_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	001	0	1	04	01	H4408_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	001	0	1	04	01	H4408_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	001	0	1	04	01	H4408_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	002	0	1	04	01	H4408_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	002	0	1	04	01	H4408_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	002	0	1	04	01	H4408_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	002	0	1	04	01	H4408_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	002	0	1	04	01	H4408_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	002	0	1	04	01	H4408_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	002	0	1	04	01	H4408_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	002	0	1	04	01	H4408_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	006	0	1	04	01	H4408_006_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	006	0	1	04	01	H4408_006_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	006	0	1	04	01	H4408_006_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	006	0	1	04	01	H4408_006_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	006	0	1	04	01	H4408_006_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	006	0	1	04	01	H4408_006_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	006	0	1	04	01	H4408_006_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	006	0	1	04	01	H4408_006_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	007	0	1	04	01	H4408_007_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	007	0	1	04	01	H4408_007_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	007	0	1	04	01	H4408_007_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	007	0	1	04	01	H4408_007_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4408	007	0	1	04	01	H4408_007_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4408	007	0	1	04	01	H4408_007_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4408	007	0	1	04	01	H4408_007_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4408	007	0	1	04	01	H4408_007_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4449	013	0	1	09	04	H4449_013_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00
H4449	013	0	1	09	04	H4449_013_0	8	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4449	013	0	1	09	04	H4449_013_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00
H4454	002	0	1	01	01	H4454_002_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	002	0	1	01	01	H4454_002_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	002	0	1	01	01	H4454_002_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	002	0	1	01	01	H4454_002_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	002	0	1	01	01	H4454_002_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	002	0	1	01	01	H4454_002_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H4454	002	0	1	01	01	H4454_002_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	002	0	1	01	01	H4454_002_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	002	0	1	01	01	H4454_002_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	002	0	1	01	01	H4454_002_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	007	0	1	01	01	H4454_007_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	007	0	1	01	01	H4454_007_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	007	0	1	01	01	H4454_007_0	3	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	007	0	1	01	01	H4454_007_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	007	0	1	01	01	H4454_007_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	007	0	1	01	01	H4454_007_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	007	0	1	01	01	H4454_007_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	007	0	1	01	01	H4454_007_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	007	0	1	01	01	H4454_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	007	0	1	01	01	H4454_007_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	018	0	1	01	01	H4454_018_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	018	0	1	01	01	H4454_018_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	018	0	1	01	01	H4454_018_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	018	0	1	01	01	H4454_018_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	018	0	1	01	01	H4454_018_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	018	0	1	01	01	H4454_018_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	018	0	1	01	01	H4454_018_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	018	0	1	01	01	H4454_018_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	018	0	1	01	01	H4454_018_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	018	0	1	01	01	H4454_018_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	019	0	1	01	01	H4454_019_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	019	0	1	01	01	H4454_019_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	019	0	1	01	01	H4454_019_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	019	0	1	01	01	H4454_019_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	019	0	1	01	01	H4454_019_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	019	0	1	01	01	H4454_019_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	019	0	1	01	01	H4454_019_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4454	019	0	1	01	01	H4454_019_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4454	019	0	1	01	01	H4454_019_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.0
H4454	019	0	1	01	01	H4454_019_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	021	0	1	01	01	H4454_021_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	021	0	1	01	01	H4454_021_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	021	0	1	01	01	H4454_021_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	021	0	1	01	01	H4454_021_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H4454	021	0	1	01	01	H4454_021_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	021	0	1	01	01	H4454_021_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	021	0	1	01	01	H4454_021_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	021	0	1	01	01	H4454_021_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	021	0	1	01	01	H4454_021_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	021	0	1	01	01	H4454_021_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	022	0	1	01	01	H4454_022_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	022	0	1	01	01	H4454_022_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	022	0	1	01	01	H4454_022_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	022	0	1	01	01	H4454_022_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	022	0	1	01	01	H4454_022_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	022	0	1	01	01	H4454_022_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	022	0	1	01	01	H4454_022_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	022	0	1	01	01	H4454_022_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	022	0	1	01	01	H4454_022_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	022	0	1	01	01	H4454_022_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	023	0	1	01	01	H4454_023_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	023	0	1	01	01	H4454_023_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	023	0	1	01	01	H4454_023_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	023	0	1	01	01	H4454_023_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	023	0	1	01	01	H4454_023_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	023	0	1	01	01	H4454_023_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	023	0	1	01	01	H4454_023_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	023	0	1	01	01	H4454_023_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4454	023	0	1	01	01	H4454_023_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4454	023	0	1	01	01	H4454_023_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4454	024	0	1	01	01	H4454_024_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	024	0	1	01	01	H4454_024_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4454	024	0	1	01	01	H4454_024_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	024	0	1	01	01	H4454_024_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	024	0	1	01	01	H4454_024_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	024	0	1	01	01	H4454_024_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	024	0	1	01	01	H4454_024_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	024	0	1	01	01	H4454_024_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	024	0	1	01	01	H4454_024_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	024	0	1	01	01	H4454_024_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	025	0	1	01	01	H4454_025_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	025	0	1	01	01	H4454_025_0	2	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	025	0	1	01	01	H4454_025_0	2	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	025	0	1	01	01	H4454_025_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	025	0	1	01	01	H4454_025_0	2	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4454	025	0	1	01	01	H4454_025_0	2	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	025	0	1	01	01	H4454_025_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	025	0	1	01	01	H4454_025_0	2	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	025	0	1	01	01	H4454_025_0	2	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	025	0	1	01	01	H4454_025_0	2	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4454	027	0	1	01	01	H4454_027_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	027	0	1	01	01	H4454_027_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4454	027	0	1	01	01	H4454_027_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4454	027	0	1	01	01	H4454_027_0	6	2	4	3	Generic	010000	1	2	1	00001000	2	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	027	0	1	01	01	H4454_027_0	6	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4454	027	0	1	01	01	H4454_027_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4454	027	0	1	01	01	H4454_027_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4454	027	0	1	01	01	H4454_027_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4454	027	0	1	01	01	H4454_027_0	6	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4454	027	0	1	01	01	H4454_027_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4456	010	0	1	01	01	H4456_010_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	010	0	1	01	01	H4456_010_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	010	0	1	01	01	H4456_010_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	010	0	1	01	01	H4456_010_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	013	0	1	01	01	H4456_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	013	0	1	01	01	H4456_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	013	0	1	01	01	H4456_013_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	013	0	1	01	01	H4456_013_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	015	0	1	01	01	H4456_015_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	40.00	120.00								40.00						110.00			120.00		40.00
H4456	015	0	1	01	01	H4456_015_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00						20.00			30.00		10.00
H4456	015	0	1	01	01	H4456_015_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	015	0	1	01	01	H4456_015_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	017	0	1	01	01	H4456_017_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	017	0	1	01	01	H4456_017_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00						20.00			30.00		10.00
H4456	017	0	1	01	01	H4456_017_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	40.00	120.00								40.00						110.00			120.00		40.00
H4456	017	0	1	01	01	H4456_017_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	019	0	1	01	01	H4456_019_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						0.00			12.00		4.00
H4456	019	0	1	01	01	H4456_019_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	019	0	1	01	01	H4456_019_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	019	0	1	01	01	H4456_019_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	021	0	1	01	01	H4456_021_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	021	0	1	01	01	H4456_021_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4456	021	0	1	01	01	H4456_021_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00						80.00			90.00		30.00
H4456	021	0	1	01	01	H4456_021_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	024	0	1	02	01	H4456_024_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	024	0	1	02	01	H4456_024_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	024	0	1	02	01	H4456_024_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H4456	024	0	1	02	01	H4456_024_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H4456	025	0	1	01	01	H4456_025_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	025	0	1	01	01	H4456_025_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	025	0	1	01	01	H4456_025_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	025	0	1	01	01	H4456_025_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	026	0	1	02	01	H4456_026_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4456	026	0	1	02	01	H4456_026_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	026	0	1	02	01	H4456_026_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4456	026	0	1	02	01	H4456_026_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	027	0	1	02	01	H4456_027_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						0.00			12.00		4.00
H4456	027	0	1	02	01	H4456_027_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4456	027	0	1	02	01	H4456_027_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4456	027	0	1	02	01	H4456_027_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4461	001	0	1	01	01	H4461_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H4461	001	0	1	01	01	H4461_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H4461	001	0	1	01	01	H4461_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H4461	001	0	1	01	01	H4461_001_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4461	012	0	1	01	01	H4461_012_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H4461	012	0	1	01	01	H4461_012_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H4461	012	0	1	01	01	H4461_012_0	7	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4461	012	0	1	01	01	H4461_012_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H4461	015	0	1	01	01	H4461_015_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H4461	015	0	1	01	01	H4461_015_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H4461	015	0	1	01	01	H4461_015_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H4461	015	0	1	01	01	H4461_015_0	11	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4461	016	0	1	01	01	H4461_016_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	10.00	30.00								10.00		10.00	30.00								10.00
H4461	016	0	1	01	01	H4461_016_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	31.00	93.00								31.00		31.00	93.00								31.00
H4461	016	0	1	01	01	H4461_016_0	10	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4461	016	0	1	01	01	H4461_016_0	10	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4461	016	0	1	01	01	H4461_016_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4461	016	0	1	01	01	H4461_016_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	12.00	36.00								12.00		12.00	36.00								12.00
H4461	016	0	1	01	01	H4461_016_0	10	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4461	016	0	1	01	01	H4461_016_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H4461	017	0	1	01	01	H4461_017_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H4461	017	0	1	01	01	H4461_017_0	10	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4461	017	0	1	01	01	H4461_017_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4461	017	0	1	01	01	H4461_017_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H4461	017	0	1	01	01	H4461_017_0	10	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4461	017	0	1	01	01	H4461_017_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H4461	017	0	1	01	01	H4461_017_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H4461	017	0	1	01	01	H4461_017_0	10	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4506	003	0	1	01	01	H4506_003_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H4506	003	0	1	01	01	H4506_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00											30.00
H4506	003	0	1	01	01	H4506_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H4506	003	0	1	01	01	H4506_003_0	5	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H4506	003	0	1	01	01	H4506_003_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H4506	003	0	1	01	01	H4506_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4506	003	0	1	01	01	H4506_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4506	003	0	1	01	01	H4506_003_0	5	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4506	023	0	1	01	01	H4506_023_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H4506	023	0	1	01	01	H4506_023_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00											30.00
H4506	023	0	1	01	01	H4506_023_0	6	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H4506	023	0	1	01	01	H4506_023_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H4506	025	0	1	01	01	H4506_025_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H4506	025	0	1	01	01	H4506_025_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	62.50								25.00											25.00
H4506	025	0	1	01	01	H4506_025_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	125.00								50.00											50.00
H4506	025	0	1	01	01	H4506_025_0	6	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H4506	025	0	1	01	01	H4506_025_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H4506	025	0	1	01	01	H4506_025_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4506	025	0	1	01	01	H4506_025_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4506	025	0	1	01	01	H4506_025_0	6	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4510	012	0	1	01	01	H4510_012_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	012	0	1	01	01	H4510_012_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H4510	012	0	1	01	01	H4510_012_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	012	0	1	01	01	H4510_012_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	012	0	1	01	01	H4510_012_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00
H4510	012	0	1	01	01	H4510_012_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	012	0	1	01	01	H4510_012_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	012	0	1	01	01	H4510_012_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	015	0	1	01	01	H4510_015_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	015	0	1	01	01	H4510_015_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	015	0	1	01	01	H4510_015_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H4510	015	0	1	01	01	H4510_015_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	015	0	1	01	01	H4510_015_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	015	0	1	01	01	H4510_015_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	015	0	1	01	01	H4510_015_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00
H4510	015	0	1	01	01	H4510_015_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	017	0	1	01	01	H4510_017_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4510	017	0	1	01	01	H4510_017_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4510	017	0	1	01	01	H4510_017_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	017	0	1	01	01	H4510_017_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	017	0	1	01	01	H4510_017_0	4	4	4	3	Specialty	100100	1	1	1	10000000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	017	0	1	01	01	H4510_017_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4510	017	0	1	01	01	H4510_017_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4510	017	0	1	01	01	H4510_017_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	018	0	1	01	01	H4510_018_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4510	018	0	1	01	01	H4510_018_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	018	0	1	01	01	H4510_018_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	018	0	1	01	01	H4510_018_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H4510	018	0	1	01	01	H4510_018_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4510	018	0	1	01	01	H4510_018_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4510	018	0	1	01	01	H4510_018_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	018	0	1	01	01	H4510_018_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
H4510	019	0	1	01	01	H4510_019_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	019	0	1	01	01	H4510_019_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4510	019	0	1	01	01	H4510_019_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4510	019	0	1	01	01	H4510_019_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4510	019	0	1	01	01	H4510_019_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4510	019	0	1	01	01	H4510_019_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4510	019	0	1	01	01	H4510_019_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4510	019	0	1	01	01	H4510_019_0	4	4	4	3	Specialty	100100	1	1	1	10000000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4513	001	0	1	01	01	H4513_001_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4513	001	0	1	01	01	H4513_001_0	3	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4513	001	0	1	01	01	H4513_001_0	3	2	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4513	001	0	1	01	01	H4513_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	001	0	1	01	01	H4513_001_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4513	001	0	1	01	01	H4513_001_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	001	0	1	01	01	H4513_001_0	3	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4513	001	0	1	01	01	H4513_001_0	3	3	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4513	001	0	1	01	01	H4513_001_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4513	001	0	1	01	01	H4513_001_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4513	014	0	1	01	01	H4513_014_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4513	014	0	1	01	01	H4513_014_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4513	014	0	1	01	01	H4513_014_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4513	014	0	1	01	01	H4513_014_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4513	014	0	1	01	01	H4513_014_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4513	014	0	1	01	01	H4513_014_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4513	014	0	1	01	01	H4513_014_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4513	014	0	1	01	01	H4513_014_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4513	014	0	1	01	01	H4513_014_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4513	014	0	1	01	01	H4513_014_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4513	019	0	1	01	01	H4513_019_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	019	0	1	01	01	H4513_019_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4513	019	0	1	01	01	H4513_019_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4513	019	0	1	01	01	H4513_019_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4513	019	0	1	01	01	H4513_019_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4513	019	0	1	01	01	H4513_019_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4513	019	0	1	01	01	H4513_019_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4513	019	0	1	01	01	H4513_019_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	019	0	1	01	01	H4513_019_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4513	019	0	1	01	01	H4513_019_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4513	020	0	1	01	01	H4513_020_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4513	020	0	1	01	01	H4513_020_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4513	020	0	1	01	01	H4513_020_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4513	020	0	1	01	01	H4513_020_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4513	020	0	1	01	01	H4513_020_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4513	020	0	1	01	01	H4513_020_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50
H4513	020	0	1	01	01	H4513_020_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50
H4513	020	0	1	01	01	H4513_020_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00
H4513	020	0	1	01	01	H4513_020_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																					
H4513	020	0	1	01	01	H4513_020_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4513	021	0	1	01	01	H4513_021_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	021	0	1	01	01	H4513_021_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4513	021	0	1	01	01	H4513_021_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4513	021	0	1	01	01	H4513_021_0	4	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4513	021	0	1	01	01	H4513_021_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4513	021	0	1	01	01	H4513_021_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H4513	021	0	1	01	01	H4513_021_0	4	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4513	021	0	1	01	01	H4513_021_0	4	3	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4513	021	0	1	01	01	H4513_021_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4513	021	0	1	01	01	H4513_021_0	4	2	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4514	004	0	1	01	01	H4514_004_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4514	004	0	1	01	01	H4514_004_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4514	004	0	1	01	01	H4514_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4514	004	0	1	01	01	H4514_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4514	004	0	1	01	01	H4514_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4514	004	0	1	01	01	H4514_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4514	004	0	1	01	01	H4514_004_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4514	004	0	1	01	01	H4514_004_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4514	005	0	1	01	01	H4514_005_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H4514	005	0	1	01	01	H4514_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H4514	005	0	1	01	01	H4514_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4514	005	0	1	01	01	H4514_005_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4514	007	0	1	01	01	H4514_007_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H4514	007	0	1	01	01	H4514_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H4514	007	0	1	01	01	H4514_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4514	007	0	1	01	01	H4514_007_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4514	007	0	1	01	01	H4514_007_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4514	007	0	1	01	01	H4514_007_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4514	007	0	1	01	01	H4514_007_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4514	007	0	1	01	01	H4514_007_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4514	010	0	1	01	01	H4514_010_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H4514	010	0	1	01	01	H4514_010_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4514	010	0	1	01	01	H4514_010_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H4514	010	0	1	01	01	H4514_010_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4520	001	0	1	04	01	H4520_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	001	0	1	04	01	H4520_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	001	0	1	04	01	H4520_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	001	0	1	04	01	H4520_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	001	0	1	04	01	H4520_001_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	001	0	1	04	01	H4520_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	001	0	1	04	01	H4520_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	001	0	1	04	01	H4520_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	002	0	1	04	01	H4520_002_0	10	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	002	0	1	04	01	H4520_002_0	10	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H4520	002	0	1	04	01	H4520_002_0	10	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	002	0	1	04	01	H4520_002_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	002	0	1	04	01	H4520_002_0	10	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	002	0	1	04	01	H4520_002_0	10	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	002	0	1	04	01	H4520_002_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H4520	002	0	1	04	01	H4520_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	003	0	1	04	01	H4520_003_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4520	003	0	1	04	01	H4520_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H4520	003	0	1	04	01	H4520_003_0	9	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	003	0	1	04	01	H4520_003_0	9	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4520	003	0	1	04	01	H4520_003_0	9	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	003	0	1	04	01	H4520_003_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H4520	003	0	1	04	01	H4520_003_0	9	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	003	0	1	04	01	H4520_003_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	005	0	1	04	01	H4520_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	005	0	1	04	01	H4520_005_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	005	0	1	04	01	H4520_005_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	005	0	1	04	01	H4520_005_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4520	005	0	1	04	01	H4520_005_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H4520	005	0	1	04	01	H4520_005_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	005	0	1	04	01	H4520_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	005	0	1	04	01	H4520_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4520	006	0	1	04	01	H4520_006_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	006	0	1	04	01	H4520_006_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4520	006	0	1	04	01	H4520_006_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4520	006	0	1	04	01	H4520_006_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	006	0	1	04	01	H4520_006_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4520	006	0	1	04	01	H4520_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4520	006	0	1	04	01	H4520_006_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	006	0	1	04	01	H4520_006_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	016	0	1	04	01	H4520_016_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	016	0	1	04	01	H4520_016_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	016	0	1	04	01	H4520_016_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	016	0	1	04	01	H4520_016_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	016	0	1	04	01	H4520_016_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	016	0	1	04	01	H4520_016_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	016	0	1	04	01	H4520_016_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4520	016	0	1	04	01	H4520_016_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4520	018	0	1	04	01	H4520_018_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4520	018	0	1	04	01	H4520_018_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4520	018	0	1	04	01	H4520_018_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	018	0	1	04	01	H4520_018_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	018	0	1	04	01	H4520_018_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4520	018	0	1	04	01	H4520_018_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00
H4520	018	0	1	04	01	H4520_018_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00
H4520	018	0	1	04	01	H4520_018_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00
H4521	001	0	1	01	01	H4521_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00		6.00	18.00								6.00
H4521	001	0	1	01	01	H4521_001_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00		30.00	90.00								30.00
H4521	001	0	1	01	01	H4521_001_0	6	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4521	001	0	1	01	01	H4521_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00		6.00	18.00								6.00
H4521	001	0	1	01	01	H4521_001_0	6	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H4521	001	0	1	01	01	H4521_001_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4521	004	0	1	01	01	H4521_004_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00		6.00	18.00								6.00
H4521	004	0	1	01	01	H4521_004_0	4	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4521	004	0	1	01	01	H4521_004_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00		30.00	90.00								30.00
H4522	001	0	1	04	01	H4522_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4522	001	0	1	04	01	H4522_001_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4522	001	0	1	04	01	H4522_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4522	001	0	1	04	01	H4522_001_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4522	001	0	1	04	01	H4522_001_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4522	001	0	1	04	01	H4522_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H4522	001	0	1	04	01	H4522_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4522	001	0	1	04	01	H4522_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H4522	008	0	1	04	01	H4522_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4522	008	0	1	04	01	H4522_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4522	008	0	1	04	01	H4522_008_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4522	008	0	1	04	01	H4522_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4522	008	0	1	04	01	H4522_008_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4522	008	0	1	04	01	H4522_008_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4522	008	0	1	04	01	H4522_008_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4522	008	0	1	04	01	H4522_008_0	3	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4523	001	0	1	01	01	H4523_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4523	001	0	1	01	01	H4523_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4523	001	0	1	01	01	H4523_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4523	001	0	1	01	01	H4523_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	001	0	1	01	01	H4523_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4523	001	0	1	01	01	H4523_001_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	001	0	1	01	01	H4523_001_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4523	001	0	1	01	01	H4523_001_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4523	001	0	1	01	01	H4523_001_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4523	001	0	1	01	01	H4523_001_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4523	005	0	1	01	01	H4523_005_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4523	005	0	1	01	01	H4523_005_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				2.00	5.00		2.00	6.00			2.00					4.00			6.00		2.00
H4523	005	0	1	01	01	H4523_005_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				45.00	112.50		45.00	135.00			45.00					90.00			135.00		45.00
H4523	005	0	1	01	01	H4523_005_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					160.00			240.00		80.00
H4523	005	0	1	01	01	H4523_005_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4523	009	0	1	01	01	H4523_009_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4523	009	0	1	01	01	H4523_009_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4523	009	0	1	01	01	H4523_009_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4523	009	0	1	01	01	H4523_009_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4523	009	0	1	01	01	H4523_009_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	009	0	1	01	01	H4523_009_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4523	009	0	1	01	01	H4523_009_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4523	009	0	1	01	01	H4523_009_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4523	009	0	1	01	01	H4523_009_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	009	0	1	01	01	H4523_009_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4523	010	0	1	01	01	H4523_010_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4523	010	0	1	01	01	H4523_010_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4523	010	0	1	01	01	H4523_010_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H4523	010	0	1	01	01	H4523_010_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H4523	010	0	1	01	01	H4523_010_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4523	012	0	1	01	01	H4523_012_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H4523	012	0	1	01	01	H4523_012_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4523	012	0	1	01	01	H4523_012_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H4523	012	0	1	01	01	H4523_012_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4523	012	0	1	01	01	H4523_012_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4523	014	0	1	01	01	H4523_014_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4523	014	0	1	01	01	H4523_014_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H4523	014	0	1	01	01	H4523_014_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
H4523	014	0	1	01	01	H4523_014_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4523	014	0	1	01	01	H4523_014_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				70.00	175.00		70.00	210.00			70.00					140.00			210.00		70.00
H4523	015	0	1	01	01	H4523_015_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4523	015	0	1	01	01	H4523_015_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4523	015	0	1	01	01	H4523_015_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4523	015	0	1	01	01	H4523_015_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	015	0	1	01	01	H4523_015_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4523	015	0	1	01	01	H4523_015_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4523	015	0	1	01	01	H4523_015_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4523	015	0	1	01	01	H4523_015_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4523	015	0	1	01	01	H4523_015_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4523	015	0	1	01	01	H4523_015_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	001	0	1	04	01	H4524_001_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4524	001	0	1	04	01	H4524_001_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4524	001	0	1	04	01	H4524_001_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	001	0	1	04	01	H4524_001_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H4524	001	0	1	04	01	H4524_001_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4524	002	0	1	04	01	H4524_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	002	0	1	04	01	H4524_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	002	0	1	04	01	H4524_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4524	002	0	1	04	01	H4524_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4524	002	0	1	04	01	H4524_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	002	0	1	04	01	H4524_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4524	002	0	1	04	01	H4524_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4524	002	0	1	04	01	H4524_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	002	0	1	04	01	H4524_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	002	0	1	04	01	H4524_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4524	003	0	1	04	01	H4524_003_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H4524	003	0	1	04	01	H4524_003_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	003	0	1	04	01	H4524_003_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4524	003	0	1	04	01	H4524_003_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4524	003	0	1	04	01	H4524_003_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4524	005	0	1	04	01	H4524_005_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H4524	005	0	1	04	01	H4524_005_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	005	0	1	04	01	H4524_005_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4524	005	0	1	04	01	H4524_005_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4524	005	0	1	04	01	H4524_005_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4524	007	0	1	04	01	H4524_007_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H4524	007	0	1	04	01	H4524_007_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	007	0	1	04	01	H4524_007_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4524	007	0	1	04	01	H4524_007_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4524	007	0	1	04	01	H4524_007_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4524	008	0	1	04	01	H4524_008_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	008	0	1	04	01	H4524_008_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	008	0	1	04	01	H4524_008_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4524	008	0	1	04	01	H4524_008_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4524	008	0	1	04	01	H4524_008_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4524	008	0	1	04	01	H4524_008_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	008	0	1	04	01	H4524_008_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	008	0	1	04	01	H4524_008_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4524	008	0	1	04	01	H4524_008_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4524	008	0	1	04	01	H4524_008_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	009	0	1	04	01	H4524_009_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H4524	009	0	1	04	01	H4524_009_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	009	0	1	04	01	H4524_009_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				66.00	165.00		66.00	198.00			66.00					132.00			198.00		66.00
H4524	009	0	1	04	01	H4524_009_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H4524	009	0	1	04	01	H4524_009_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H4524	011	0	1	04	01	H4524_011_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					160.00			240.00		80.00
H4524	011	0	1	04	01	H4524_011_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				45.00	112.50		45.00	135.00			45.00					90.00			135.00		45.00
H4524	011	0	1	04	01	H4524_011_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				2.00	5.00		2.00	6.00			2.00					4.00			6.00		2.00
H4524	011	0	1	04	01	H4524_011_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	011	0	1	04	01	H4524_011_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	012	0	1	04	01	H4524_012_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	012	0	1	04	01	H4524_012_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	012	0	1	04	01	H4524_012_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4524	012	0	1	04	01	H4524_012_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4524	012	0	1	04	01	H4524_012_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	012	0	1	04	01	H4524_012_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4524	012	0	1	04	01	H4524_012_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4524	012	0	1	04	01	H4524_012_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	012	0	1	04	01	H4524_012_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	012	0	1	04	01	H4524_012_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4524	013	0	1	04	01	H4524_013_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					160.00			240.00		80.00
H4524	013	0	1	04	01	H4524_013_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				45.00	112.50		45.00	135.00			45.00					90.00			135.00		45.00
H4524	013	0	1	04	01	H4524_013_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				2.00	5.00		2.00	6.00			2.00					4.00			6.00		2.00
H4524	013	0	1	04	01	H4524_013_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	013	0	1	04	01	H4524_013_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	014	0	1	04	01	H4524_014_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	014	0	1	04	01	H4524_014_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H4524	014	0	1	04	01	H4524_014_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4524	014	0	1	04	01	H4524_014_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4524	014	0	1	04	01	H4524_014_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H4524	014	0	1	04	01	H4524_014_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H4524	014	0	1	04	01	H4524_014_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4524	014	0	1	04	01	H4524_014_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H4524	014	0	1	04	01	H4524_014_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H4524	014	0	1	04	01	H4524_014_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H4525	001	0	1	01	01	H4525_001_0	5	3	2	1	Specialty	000010		1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4525	001	0	1	01	01	H4525_001_0	5	2	2	1	Brand	000010		2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	001	0	1	01	01	H4525_001_0	5	1	2	1	Generic	010000		2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	002	0	1	01	01	H4525_002_0	6	1	2	1	Generic	010000		2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	002	0	1	01	01	H4525_002_0	6	3	2	1	Specialty	000010		1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H4525	002	0	1	01	01	H4525_002_0	6	2	2	1	Brand	000010		2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	006	0	1	01	01	H4525_006_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	006	0	1	01	01	H4525_006_0	6	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4525	006	0	1	01	01	H4525_006_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	006	0	1	01	01	H4525_006_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	006	0	1	01	01	H4525_006_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4525	006	0	1	01	01	H4525_006_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4525	007	0	1	01	01	H4525_007_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	007	0	1	01	01	H4525_007_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	007	0	1	01	01	H4525_007_0	5	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4525	007	0	1	01	01	H4525_007_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	007	0	1	01	01	H4525_007_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4525	007	0	1	01	01	H4525_007_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4525	008	0	1	01	01	H4525_008_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	008	0	1	01	01	H4525_008_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	008	0	1	01	01	H4525_008_0	5	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4525	008	0	1	01	01	H4525_008_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	008	0	1	01	01	H4525_008_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4525	008	0	1	01	01	H4525_008_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4525	009	0	1	01	01	H4525_009_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	009	0	1	01	01	H4525_009_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	31	90								31		31								90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4525	009	0	1	01	01	H4525_009_0	6	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4525	009	0	1	01	01	H4525_009_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H4525	009	0	1	01	01	H4525_009_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4525	009	0	1	01	01	H4525_009_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4527	001	0	1	01	01	H4527_001_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	001	0	1	01	01	H4527_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00			45.00								15.00
H4527	001	0	1	01	01	H4527_001_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00								50.00			150.00								50.00
H4527	001	0	1	01	01	H4527_001_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	001	0	1	01	01	H4527_001_0	4	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	001	0	1	01	01	H4527_001_0	4	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00			45.00								15.00
H4527	001	0	1	01	01	H4527_001_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	001	0	1	01	01	H4527_001_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	002	0	1	01	01	H4527_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	002	0	1	01	01	H4527_002_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	002	0	1	01	01	H4527_002_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	002	0	1	01	01	H4527_002_0	4	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	002	0	1	01	01	H4527_002_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	002	0	1	01	01	H4527_002_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	002	0	1	01	01	H4527_002_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	002	0	1	01	01	H4527_002_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	005	0	1	01	01	H4527_005_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	005	0	1	01	01	H4527_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	005	0	1	01	01	H4527_005_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	005	0	1	01	01	H4527_005_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	005	0	1	01	01	H4527_005_0	4	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	005	0	1	01	01	H4527_005_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	005	0	1	01	01	H4527_005_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	005	0	1	01	01	H4527_005_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	008	0	1	01	01	H4527_008_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00								50.00			150.00								50.00
H4527	008	0	1	01	01	H4527_008_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H4527	008	0	1	01	01	H4527_008_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	008	0	1	01	01	H4527_008_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	008	0	1	01	01	H4527_008_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	008	0	1	01	01	H4527_008_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	008	0	1	01	01	H4527_008_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	008	0	1	01	01	H4527_008_0	4	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	011	0	1	01	01	H4527_011_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	011	0	1	01	01	H4527_011_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H4527	011	0	1	01	01	H4527_011_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00								50.00			150.00								50.00
H4527	011	0	1	01	01	H4527_011_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	011	0	1	01	01	H4527_011_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	011	0	1	01	01	H4527_011_0	4	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	011	0	1	01	01	H4527_011_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	011	0	1	01	01	H4527_011_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	013	0	1	01	01	H4527_013_0	5	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	013	0	1	01	01	H4527_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	013	0	1	01	01	H4527_013_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	013	0	1	01	01	H4527_013_0	5	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	014	0	1	01	01	H4527_014_0	5	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	014	0	1	01	01	H4527_014_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	014	0	1	01	01	H4527_014_0	5	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	014	0	1	01	01	H4527_014_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	014	0	1	01	01	H4527_014_0	5	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4527	014	0	1	01	01	H4527_014_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	014	0	1	01	01	H4527_014_0	5	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	014	0	1	01	01	H4527_014_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	017	0	1	01	01	H4527_017_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	017	0	1	01	01	H4527_017_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	017	0	1	01	01	H4527_017_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	017	0	1	01	01	H4527_017_0	4	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	018	0	1	01	01	H4527_018_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H4527	018	0	1	01	01	H4527_018_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4527	018	0	1	01	01	H4527_018_0	5	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	018	0	1	01	01	H4527_018_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4527	018	0	1	01	01	H4527_018_0	5	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H4527	018	0	1	01	01	H4527_018_0	5	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	018	0	1	01	01	H4527_018_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H4527	018	0	1	01	01	H4527_018_0	5	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H4527	023	0	1	01	01	H4527_023_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	20									20											20	Specialty Drugs																					
H4527	023	0	1	01	01	H4527_023_0	3	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H4527	023	0	1	01	01	H4527_023_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H4527	023	0	1	01	01	H4527_023_0	3	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H4528	001	0	1	02	01	H4528_001_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4528	001	0	1	02	01	H4528_001_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4528	001	0	1	02	01	H4528_001_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4528	001	0	1	02	01	H4528_001_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4528	005	0	1	02	01	H4528_005_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4528	005	0	1	02	01	H4528_005_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4528	005	0	1	02	01	H4528_005_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4528	005	0	1	02	01	H4528_005_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4528	009	0	1	01	01	H4528_009_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4528	009	0	1	01	01	H4528_009_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4528	009	0	1	01	01	H4528_009_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4528	009	0	1	01	01	H4528_009_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4528	010	0	1	01	01	H4528_010_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H4528	010	0	1	01	01	H4528_010_0	2	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H4528	010	0	1	01	01	H4528_010_0	2	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H4528	010	0	1	01	01	H4528_010_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H4529	002	0	1	01	01	H4529_002_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H4529	002	0	1	01	01	H4529_002_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H4529	002	0	1	01	01	H4529_002_0	9	3	4	1	Tier 3 - Non - Preferred Brand	100000	1	2				Tier 3 - Non - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non - Preferred Brand	2	2	Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H4529	002	0	1	01	01	H4529_002_0	9	4	4	1	Tier 4 - Specialty Drugs	000010	1	1				Tier 4 - Specialty Drugs	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drugs	2	4	Tier 4 - Specialty Drugs	25	25								25						25			25		25	Tier 4 - Specialty Drugs	200.00	600.00								200.00						600.00			600.00		200.00
H4529	002	0	1	01	01	H4529_002_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H4529	002	0	1	01	01	H4529_002_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4529	002	0	1	01	01	H4529_002_0	9	4	4	3	Tier 4 - Specialty Drugs	000010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H4529	002	0	1	01	01	H4529_002_0	9	3	4	3	Tier 3 - Non - Preferred Brand	100000	1	2	2			Tier 3 - Non - Preferred Brand																							Tier 3 - Non - Preferred Brand			Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand																					
H4529	004	0	1	01	01	H4529_004_0	11	4	4	3	Tier 4 - Specialty Drugs	000010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H4529	004	0	1	01	01	H4529_004_0	11	3	4	3	Tier 3 - Non - Preferred Brand	100000	1	2	2			Tier 3 - Non - Preferred Brand																							Tier 3 - Non - Preferred Brand			Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand																					
H4529	004	0	1	01	01	H4529_004_0	11	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4529	004	0	1	01	01	H4529_004_0	11	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H4529	004	0	1	01	01	H4529_004_0	11	4	4	1	Tier 4 - Specialty Drugs	000010	1	1				Tier 4 - Specialty Drugs	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drugs	2	4	Tier 4 - Specialty Drugs	25	25								25						25			25		25	Tier 4 - Specialty Drugs	200.00	600.00								200.00						600.00			600.00		200.00
H4529	004	0	1	01	01	H4529_004_0	11	3	4	1	Tier 3 - Non - Preferred Brand	100000	1	2				Tier 3 - Non - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non - Preferred Brand	2	2	Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H4529	004	0	1	01	01	H4529_004_0	11	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H4529	004	0	1	01	01	H4529_004_0	11	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						0.00			15.00		5.00
H4529	014	0	1	01	01	H4529_014_0	12	4	4	3	Tier 4 - Specialty Drugs	000010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H4529	014	0	1	01	01	H4529_014_0	12	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H4529	014	0	1	01	01	H4529_014_0	12	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H4529	014	0	1	01	01	H4529_014_0	12	4	4	1	Tier 4 - Specialty Drugs	000010	1	1				Tier 4 - Specialty Drugs	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drugs	2	4	Tier 4 - Specialty Drugs	25	25								25						25			25		25	Tier 4 - Specialty Drugs	200.00	600.00								200.00						600.00			600.00		200.00
H4529	014	0	1	01	01	H4529_014_0	12	3	4	1	Tier 3 - Non - Preferred Brand	100000	1	2				Tier 3 - Non - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non - Preferred Brand	2	2	Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H4529	014	0	1	01	01	H4529_014_0	12	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H4529	014	0	1	01	01	H4529_014_0	12	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H4529	014	0	1	01	01	H4529_014_0	12	3	4	3	Tier 3 - Non - Preferred Brand	100000	1	2	2			Tier 3 - Non - Preferred Brand																							Tier 3 - Non - Preferred Brand			Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand																					
H4531	001	0	1	04	01	H4531_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H4531	001	0	1	04	01	H4531_001_0	9	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				70.00	175.00		70.00	210.00		70.00			175.00								70.00
H4531	001	0	1	04	01	H4531_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				40.00	100.00		40.00	120.00		40.00			100.00								40.00
H4531	001	0	1	04	01	H4531_001_0	9	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00			17.50								7.00
H4531	003	0	1	04	01	H4531_003_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00
H4531	003	0	1	04	01	H4531_003_0	7	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				10.00	25.00		10.00	30.00		10.00			25.00								10.00
H4531	003	0	1	04	01	H4531_003_0	7	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H4531	003	0	1	04	01	H4531_003_0	7	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				80.00	200.00		80.00	240.00		80.00			200.00								80.00
H4531	004	0	1	04	01	H4531_004_0	8	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H4531	004	0	1	04	01	H4531_004_0	8	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H4531	004	0	1	04	01	H4531_004_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4531	004	0	1	04	01	H4531_004_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
H4531	004	0	1	04	01	H4531_004_0	8	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
H4531	004	0	1	04	01	H4531_004_0	8	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
H4531	004	0	1	04	01	H4531_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				38.00	95.00		38.00	114.00		38.00			95.00								38.00
H4531	004	0	1	04	01	H4531_004_0	8	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
H4564	001	0	1	18	06	H4564_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	001	0	1	18	06	H4564_001_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00		7.00	14.00								7.00
H4564	001	0	1	18	06	H4564_001_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	64.00	192.00	128.00							64.00		64.00	128.00								64.00
H4564	001	0	1	18	06	H4564_001_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	002	0	1	18	06	H4564_002_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	64.00	192.00	128.00							64.00		64.00	128.00								64.00
H4564	002	0	1	18	06	H4564_002_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00		7.00	14.00								7.00
H4564	002	0	1	18	06	H4564_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	002	0	1	18	06	H4564_002_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	003	0	1	18	06	H4564_003_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	003	0	1	18	06	H4564_003_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00		7.00	14.00								7.00
H4564	003	0	1	18	06	H4564_003_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	64.00	192.00	128.00							64.00		64.00	128.00								64.00
H4564	003	0	1	18	06	H4564_003_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	004	0	1	18	06	H4564_004_0	8	4	4	3	Specialty	111111	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4564	004	0	1	18	06	H4564_004_0	8	3	4	3	Non-Preferred Brand or Generic	100100	1	2	2			Non-Preferred Brand or Generic																							Non-Preferred Brand or Generic			Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																					
H4564	004	0	1	18	06	H4564_004_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4564	004	0	1	18	06	H4564_004_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00
H4564	004	0	1	18	06	H4564_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	004	0	1	18	06	H4564_004_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	65.00	195.00	130.00							65.00		65.00	130.00								65.00
H4564	004	0	1	18	06	H4564_004_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	004	0	1	18	06	H4564_004_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00								0.00
H4564	005	0	1	18	06	H4564_005_0	8	4	4	3	Specialty	111111	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4564	005	0	1	18	06	H4564_005_0	8	3	4	3	Non-Preferred Brand or Generic	100100	1	2	2			Non-Preferred Brand or Generic																							Non-Preferred Brand or Generic			Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																					
H4564	005	0	1	18	06	H4564_005_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00								0.00
H4564	005	0	1	18	06	H4564_005_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	005	0	1	18	06	H4564_005_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	65.00	195.00	130.00							65.00		65.00	130.00								65.00
H4564	005	0	1	18	06	H4564_005_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	005	0	1	18	06	H4564_005_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00
H4564	005	0	1	18	06	H4564_005_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4564	006	0	1	18	06	H4564_006_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00
H4564	006	0	1	18	06	H4564_006_0	8	3	4	3	Non-Preferred Brand or Generic	100100	1	2	2			Non-Preferred Brand or Generic																							Non-Preferred Brand or Generic			Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																					
H4564	006	0	1	18	06	H4564_006_0	8	4	4	3	Specialty	111111	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4564	006	0	1	18	06	H4564_006_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4564	006	0	1	18	06	H4564_006_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00								0.00
H4564	006	0	1	18	06	H4564_006_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
H4564	006	0	1	18	06	H4564_006_0	8	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	65.00	195.00	130.00							65.00		65.00	130.00								65.00
H4564	006	0	1	18	06	H4564_006_0	8	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
H4564	013	0	1	18	06	H4564_013_0	8	3	3	1	Non-Preferred Brand or Generic	100100		2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	60.00	180.00	120.00							60.00		60.00	120.00								60.00
H4564	013	0	1	18	06	H4564_013_0	8	4	3	1	Specialty	111111		1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	25	25	25							25		25	25								25	Specialty																					
H4564	013	0	1	18	06	H4564_013_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	99.00	66.00							33.00		33.00	66.00								33.00
H4564	013	0	1	18	06	H4564_013_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	1.00	3.00	2.00							1.00		1.00	2.00								1.00
H4564	014	0	1	18	06	H4564_014_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	99.00	66.00							33.00		33.00	66.00								33.00
H4564	014	0	1	18	06	H4564_014_0	8	3	3	1	Non-Preferred Brand or Generic	100100		2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	60.00	180.00	120.00							60.00		60.00	120.00								60.00
H4564	014	0	1	18	06	H4564_014_0	8	4	3	1	Specialty	111111		1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	25	25	25							25		25	25								25	Specialty																					
H4564	014	0	1	18	06	H4564_014_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	1.00	3.00	2.00							1.00		1.00	2.00								1.00
H4564	015	0	1	18	06	H4564_015_0	8	4	3	1	Specialty	111111		1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	25	25	25							25		25	25								25	Specialty																					
H4564	015	0	1	18	06	H4564_015_0	8	3	3	1	Non-Preferred Brand or Generic	100100		2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	60.00	180.00	120.00							60.00		60.00	120.00								60.00
H4564	015	0	1	18	06	H4564_015_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	99.00	66.00							33.00		33.00	66.00								33.00
H4564	015	0	1	18	06	H4564_015_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	1.00	3.00	2.00							1.00		1.00	2.00								1.00
H4577	012	0	1	09	04	H4577_012_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H4577	012	0	1	09	04	H4577_012_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H4577	012	0	1	09	04	H4577_012_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H4577	012	0	1	09	04	H4577_012_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4577	029	0	1	09	04	H4577_029_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H4577	029	0	1	09	04	H4577_029_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H4577	029	0	1	09	04	H4577_029_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H4577	029	0	1	09	04	H4577_029_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4577	030	0	1	09	04	H4577_030_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H4577	030	0	1	09	04	H4577_030_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H4577	030	0	1	09	04	H4577_030_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4577	030	0	1	09	04	H4577_030_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H4577	031	0	1	09	04	H4577_031_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H4577	031	0	1	09	04	H4577_031_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H4577	031	0	1	09	04	H4577_031_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H4577	031	0	1	09	04	H4577_031_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4577	032	0	1	09	04	H4577_032_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H4577	032	0	1	09	04	H4577_032_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H4577	032	0	1	09	04	H4577_032_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H4577	032	0	1	09	04	H4577_032_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H4590	010	0	1	01	01	H4590_010_0	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4590	010	0	1	01	01	H4590_010_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						0.00			87.00		29.00
H4590	010	0	1	01	01	H4590_010_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
H4590	010	0	1	01	01	H4590_010_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	010	0	1	01	01	H4590_010_0	9	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
H4590	010	0	1	01	01	H4590_010_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4590	010	0	1	01	01	H4590_010_0	9	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4590	010	0	1	01	01	H4590_010_0	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4590	012	0	1	01	01	H4590_012_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4590	012	0	1	01	01	H4590_012_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H4590	012	0	1	01	01	H4590_012_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	012	0	1	01	01	H4590_012_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	012	0	1	01	01	H4590_012_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4590	012	0	1	01	01	H4590_012_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4590	012	0	1	01	01	H4590_012_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4590	012	0	1	01	01	H4590_012_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	025	0	1	01	01	H4590_025_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	025	0	1	01	01	H4590_025_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H4590	025	0	1	01	01	H4590_025_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4590	025	0	1	01	01	H4590_025_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	031	0	1	01	01	H4590_031_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H4590	031	0	1	01	01	H4590_031_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H4590	031	0	1	01	01	H4590_031_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	031	0	1	01	01	H4590_031_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	034	0	1	01	01	H4590_034_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	034	0	1	01	01	H4590_034_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H4590	034	0	1	01	01	H4590_034_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	034	0	1	01	01	H4590_034_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H4590	035	0	1	01	01	H4590_035_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4590	035	0	1	01	01	H4590_035_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4590	035	0	1	01	01	H4590_035_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	035	0	1	01	01	H4590_035_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	035	0	1	01	01	H4590_035_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	035	0	1	01	01	H4590_035_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4590	035	0	1	01	01	H4590_035_0	6	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4590	035	0	1	01	01	H4590_035_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4590	036	0	1	01	01	H4590_036_0	7	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4590	036	0	1	01	01	H4590_036_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4590	036	0	1	01	01	H4590_036_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	036	0	1	01	01	H4590_036_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	036	0	1	01	01	H4590_036_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4590	036	0	1	01	01	H4590_036_0	7	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4590	036	0	1	01	01	H4590_036_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4590	036	0	1	01	01	H4590_036_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	037	0	1	01	01	H4590_037_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	037	0	1	01	01	H4590_037_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4590	037	0	1	01	01	H4590_037_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4590	037	0	1	01	01	H4590_037_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4590	037	0	1	01	01	H4590_037_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H4590	037	0	1	01	01	H4590_037_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4590	037	0	1	01	01	H4590_037_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4590	037	0	1	01	01	H4590_037_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H4604	003	0	1	02	01	H4604_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4604	003	0	1	02	01	H4604_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H4604	003	0	1	02	01	H4604_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4604	003	0	1	02	01	H4604_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H4604	007	0	1	02	01	H4604_007_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4604	007	0	1	02	01	H4604_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4604	007	0	1	02	01	H4604_007_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H4604	007	0	1	02	01	H4604_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H4604	008	0	1	02	01	H4604_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H4604	008	0	1	02	01	H4604_008_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H4604	008	0	1	02	01	H4604_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4604	008	0	1	02	01	H4604_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4604	009	0	1	02	01	H4604_009_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4604	009	0	1	02	01	H4604_009_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H4604	009	0	1	02	01	H4604_009_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H4604	009	0	1	02	01	H4604_009_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H4605	002	0	1	04	01	H4605_002_0	6	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H4605	002	0	1	04	01	H4605_002_0	6	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H4605	002	0	1	04	01	H4605_002_0	6	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H4605	002	0	1	04	01	H4605_002_0	6	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H4605	002	0	1	04	01	H4605_002_0	6	5	2	1	Specialty Medications	110001		1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H4605	004	0	1	04	01	H4605_004_0	7	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H4605	004	0	1	04	01	H4605_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H4605	004	0	1	04	01	H4605_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4605	004	0	1	04	01	H4605_004_0	7	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H4605	004	0	1	04	01	H4605_004_0	7	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H4605	004	0	1	04	01	H4605_004_0	7	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
H4605	004	0	1	04	01	H4605_004_0	7	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
H4605	004	0	1	04	01	H4605_004_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4605	004	0	1	04	01	H4605_004_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4605	004	0	1	04	01	H4605_004_0	7	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H4605	006	0	1	04	01	H4605_006_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H4605	006	0	1	04	01	H4605_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H4605	006	0	1	04	01	H4605_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H4605	006	0	1	04	01	H4605_006_0	5	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H4605	006	0	1	04	01	H4605_006_0	5	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H4606	001	0	1	04	01	H4606_001_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4606	001	0	1	04	01	H4606_001_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4606	001	0	1	04	01	H4606_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4606	001	0	1	04	01	H4606_001_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4606	001	0	1	04	01	H4606_001_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4606	001	0	1	04	01	H4606_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4606	001	0	1	04	01	H4606_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4606	001	0	1	04	01	H4606_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4606	004	0	1	04	01	H4606_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4606	004	0	1	04	01	H4606_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4606	004	0	1	04	01	H4606_004_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4606	004	0	1	04	01	H4606_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H4606	004	0	1	04	01	H4606_004_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H4606	004	0	1	04	01	H4606_004_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4606	004	0	1	04	01	H4606_004_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4606	004	0	1	04	01	H4606_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H4720	001	0	1	09	04	H4720_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H4720	001	0	1	09	04	H4720_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4720	001	0	1	09	04	H4720_001_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4720	001	0	1	09	04	H4720_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4779	001	0	1	37	05	H4779_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4779	001	0	1	37	05	H4779_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4779	001	0	1	37	05	H4779_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H4779	001	0	1	37	05	H4779_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H4779	003	0	1	37	05	H4779_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H4779	003	0	1	37	05	H4779_003_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H4779	003	0	1	37	05	H4779_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H4779	003	0	1	37	05	H4779_003_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4781	001	0	1	04	01	H4781_001_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H4781	001	0	1	04	01	H4781_001_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H4781	001	0	1	04	01	H4781_001_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H4781	001	0	1	04	01	H4781_001_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H4781	001	0	1	04	01	H4781_001_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H4781	002	0	1	04	01	H4781_002_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H4781	002	0	1	04	01	H4781_002_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H4781	002	0	1	04	01	H4781_002_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H4781	002	0	1	04	01	H4781_002_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H4781	002	0	1	04	01	H4781_002_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H4836	002	0	1	09	04	H4836_002_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H4836	002	0	1	09	04	H4836_002_0	10	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H4836	002	0	1	09	04	H4836_002_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H4836	002	0	1	09	04	H4836_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H4908	002	0	1	04	01	H4908_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	31	90	60							31										90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H4908	002	0	1	04	01	H4908_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111100000010010000000	31	90	60							31										90	34	Specialty	2	1	Specialty	30	30	30							30			30								30	Specialty																					
H4908	002	0	1	04	01	H4908_002_0	4	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	31	90	60							31										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H4908	002	0	1	04	01	H4908_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	31	90	60							31										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H4908	006	0	1	04	01	H4908_006_0	5	4	4	1	Specialty	010010	1	1				Specialty	111100000010010000000	31	90	60							31										90	34	Specialty	2	1	Specialty	30	30	30							30			30								30	Specialty																					
H4908	006	0	1	04	01	H4908_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	31	90	60							31										90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H4908	006	0	1	04	01	H4908_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	31	90	60							31										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H4908	006	0	1	04	01	H4908_006_0	5	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	31	90	60							31										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H4909	001	0	1	04	01	H4909_001_0	12	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H4909	001	0	1	04	01	H4909_001_0	12	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H4909	001	0	1	04	01	H4909_001_0	12	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H4909	001	0	1	04	01	H4909_001_0	12	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H4909	001	0	1	04	01	H4909_001_0	12	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H4909	001	0	1	04	01	H4909_001_0	12	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H4909	001	0	1	04	01	H4909_001_0	12	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H4909	001	0	1	04	01	H4909_001_0	12	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H4909	001	0	1	04	01	H4909_001_0	12	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H4909	001	0	1	04	01	H4909_001_0	12	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H4909	004	0	1	04	01	H4909_004_0	13	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H4909	004	0	1	04	01	H4909_004_0	13	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H4909	004	0	1	04	01	H4909_004_0	13	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H4909	004	0	1	04	01	H4909_004_0	13	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H4909	004	0	1	04	01	H4909_004_0	13	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H4909	004	0	1	04	01	H4909_004_0	13	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H4909	004	0	1	04	01	H4909_004_0	13	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H4909	004	0	1	04	01	H4909_004_0	13	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H4909	004	0	1	04	01	H4909_004_0	13	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H4909	004	0	1	04	01	H4909_004_0	13	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H4910	002	0	1	01	01	H4910_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4910	002	0	1	01	01	H4910_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H4910	002	0	1	01	01	H4910_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4910	002	0	1	01	01	H4910_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H4910	002	0	1	01	01	H4910_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H4910	002	0	1	01	01	H4910_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4910	002	0	1	01	01	H4910_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4910	002	0	1	01	01	H4910_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H4910	002	0	1	01	01	H4910_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4910	002	0	1	01	01	H4910_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H4910	004	0	1	01	01	H4910_004_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H4910	004	0	1	01	01	H4910_004_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
H4910	004	0	1	01	01	H4910_004_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H4910	004	0	1	01	01	H4910_004_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H4910	004	0	1	01	01	H4910_004_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H4910	005	0	1	01	01	H4910_005_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H4910	005	0	1	01	01	H4910_005_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H4910	005	0	1	01	01	H4910_005_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H4910	005	0	1	01	01	H4910_005_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H4910	005	0	1	01	01	H4910_005_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H4911	002	0	1	04	01	H4911_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H4911	002	0	1	04	01	H4911_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H4911	002	0	1	04	01	H4911_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H4911	002	0	1	04	01	H4911_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4911	002	0	1	04	01	H4911_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H4911	002	0	1	04	01	H4911_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H4911	002	0	1	04	01	H4911_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H4911	002	0	1	04	01	H4911_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H4911	002	0	1	04	01	H4911_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H4911	002	0	1	04	01	H4911_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H4911	003	0	1	04	01	H4911_003_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
H4911	003	0	1	04	01	H4911_003_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H4911	003	0	1	04	01	H4911_003_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H4911	003	0	1	04	01	H4911_003_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H4911	003	0	1	04	01	H4911_003_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H4917	001	0	1	09	04	H4917_001_0	11	5	4	3	Specialty Injectibles	010010	1	1	2			Specialty Injectibles																							Specialty Injectibles			Specialty Injectibles																						Specialty Injectibles																					
H4917	001	0	1	09	04	H4917_001_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4917	001	0	1	09	04	H4917_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4917	001	0	1	09	04	H4917_001_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4917	001	0	1	09	04	H4917_001_0	11	4	4	1	Non-Specialty Injectibles	010010	1	2				Non-Specialty Injectibles	111000000010010000000	30	90								30										90	31	Non-Specialty Injectibles	2	1	Non-Specialty Injectibles	33	33								33			33								33	Non-Specialty Injectibles																					
H4917	001	0	1	09	04	H4917_001_0	11	5	4	1	Specialty Injectibles	010010	1	1				Specialty Injectibles	111000000010010000000	30	90								30										90	31	Specialty Injectibles	2	1	Specialty Injectibles	33	33								33			33								33	Specialty Injectibles																					
H4917	001	0	1	09	04	H4917_001_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4917	001	0	1	09	04	H4917_001_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4917	001	0	1	09	04	H4917_001_0	11	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4917	001	0	1	09	04	H4917_001_0	11	4	4	3	Non-Specialty Injectibles	010010	1	2	2			Non-Specialty Injectibles																							Non-Specialty Injectibles			Non-Specialty Injectibles																						Non-Specialty Injectibles																					
H4917	002	0	1	09	04	H4917_002_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4917	002	0	1	09	04	H4917_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H4917	002	0	1	09	04	H4917_002_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H4917	002	0	1	09	04	H4917_002_0	10	4	4	1	Non-Specialty Injectibles	010010	1	2				Non-Specialty Injectibles	111000000010010000000	30	90								30										90	31	Non-Specialty Injectibles	2	1	Non-Specialty Injectibles	33	33								33			33								33	Non-Specialty Injectibles																					
H4917	002	0	1	09	04	H4917_002_0	10	5	4	3	Specialty Injectibles	010010	1	1	2			Specialty Injectibles																							Specialty Injectibles			Specialty Injectibles																						Specialty Injectibles																					
H4917	002	0	1	09	04	H4917_002_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H4917	002	0	1	09	04	H4917_002_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H4917	002	0	1	09	04	H4917_002_0	10	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H4917	002	0	1	09	04	H4917_002_0	10	4	4	3	Non-Specialty Injectibles	010010	1	2	2			Non-Specialty Injectibles																							Non-Specialty Injectibles			Non-Specialty Injectibles																						Non-Specialty Injectibles																					
H4917	002	0	1	09	04	H4917_002_0	10	5	4	1	Specialty Injectibles	010010	1	1				Specialty Injectibles	111000000010010000000	30	90								30										90	31	Specialty Injectibles	2	1	Specialty Injectibles	33	33								33			33								33	Specialty Injectibles																					
H4956	001	0	1	04	01	H4956_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4956	001	0	1	04	01	H4956_001_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4956	001	0	1	04	01	H4956_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4956	001	0	1	04	01	H4956_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4956	001	0	1	04	01	H4956_001_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H4956	001	0	1	04	01	H4956_001_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4956	001	0	1	04	01	H4956_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H4956	001	0	1	04	01	H4956_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H4956	002	0	1	04	01	H4956_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4956	002	0	1	04	01	H4956_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4956	002	0	1	04	01	H4956_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H4956	002	0	1	04	01	H4956_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H4956	002	0	1	04	01	H4956_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H4956	002	0	1	04	01	H4956_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H4956	002	0	1	04	01	H4956_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H4956	002	0	1	04	01	H4956_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H4971	001	0	1	02	01	H4971_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H4971	001	0	1	02	01	H4971_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H4971	001	0	1	02	01	H4971_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H4971	001	0	1	02	01	H4971_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	001	0	1	01	01	H5005_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5005	001	0	1	01	01	H5005_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5005	001	0	1	01	01	H5005_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5005	001	0	1	01	01	H5005_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	010	0	1	01	01	H5005_010_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	010	0	1	01	01	H5005_010_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5005	010	0	1	01	01	H5005_010_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5005	010	0	1	01	01	H5005_010_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5005	011	0	1	01	01	H5005_011_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5005	011	0	1	01	01	H5005_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	011	0	1	01	01	H5005_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5005	011	0	1	01	01	H5005_011_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5005	019	0	1	01	01	H5005_019_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	019	0	1	01	01	H5005_019_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5005	019	0	1	01	01	H5005_019_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5005	019	0	1	01	01	H5005_019_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5005	024	0	1	01	01	H5005_024_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5005	024	0	1	01	01	H5005_024_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H5005	024	0	1	01	01	H5005_024_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5005	024	0	1	01	01	H5005_024_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	024	0	1	01	01	H5005_024_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5005	024	0	1	01	01	H5005_024_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5005	024	0	1	01	01	H5005_024_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5005	024	0	1	01	01	H5005_024_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5006	016	1	1	09	04	H5006_016_1	3	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	016	1	1	09	04	H5006_016_1	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	016	1	1	09	04	H5006_016_1	3	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	016	1	1	09	04	H5006_016_1	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5006	016	2	1	09	04	H5006_016_2	3	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	016	2	1	09	04	H5006_016_2	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5006	016	2	1	09	04	H5006_016_2	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	016	2	1	09	04	H5006_016_2	3	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	016	3	1	09	04	H5006_016_3	3	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	016	3	1	09	04	H5006_016_3	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	016	3	1	09	04	H5006_016_3	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5006	016	3	1	09	04	H5006_016_3	3	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	017	1	1	09	04	H5006_017_1	3	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	017	1	1	09	04	H5006_017_1	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	017	1	1	09	04	H5006_017_1	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5006	017	1	1	09	04	H5006_017_1	3	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	017	2	1	09	04	H5006_017_2	3	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	017	2	1	09	04	H5006_017_2	3	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	017	2	1	09	04	H5006_017_2	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	017	2	1	09	04	H5006_017_2	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5006	017	3	1	09	04	H5006_017_3	4	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5006	017	3	1	09	04	H5006_017_3	4	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5006	017	3	1	09	04	H5006_017_3	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5006	017	3	1	09	04	H5006_017_3	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5008	001	0	1	01	01	H5008_001_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5008	001	0	1	01	01	H5008_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H5008	001	0	1	01	01	H5008_001_0	8	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H5008	001	0	1	01	01	H5008_001_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5008	004	0	1	01	01	H5008_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5008	004	0	1	01	01	H5008_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5008	004	0	1	01	01	H5008_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H5008	004	0	1	01	01	H5008_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H5008	005	0	1	01	01	H5008_005_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5008	005	0	1	01	01	H5008_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5008	005	0	1	01	01	H5008_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H5008	005	0	1	01	01	H5008_005_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H5008	006	0	1	01	01	H5008_006_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5008	006	0	1	01	01	H5008_006_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H5008	006	0	1	01	01	H5008_006_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H5008	006	0	1	01	01	H5008_006_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5009	002	0	1	04	01	H5009_002_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H5009	002	0	1	04	01	H5009_002_0	7	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5009	002	0	1	04	01	H5009_002_0	7	5	2	1	Specialty Medications	110001		1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5009	002	0	1	04	01	H5009_002_0	7	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5009	002	0	1	04	01	H5009_002_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H5009	004	0	1	04	01	H5009_004_0	6	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5009	004	0	1	04	01	H5009_004_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H5009	004	0	1	04	01	H5009_004_0	6	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
H5009	004	0	1	04	01	H5009_004_0	6	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
H5009	004	0	1	04	01	H5009_004_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5009	004	0	1	04	01	H5009_004_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5009	004	0	1	04	01	H5009_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H5009	004	0	1	04	01	H5009_004_0	6	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5009	004	0	1	04	01	H5009_004_0	6	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5009	004	0	1	04	01	H5009_004_0	6	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5009	006	0	1	04	01	H5009_006_0	5	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5009	006	0	1	04	01	H5009_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H5009	006	0	1	04	01	H5009_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H5009	006	0	1	04	01	H5009_006_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5009	006	0	1	04	01	H5009_006_0	5	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5010	002	0	1	04	01	H5010_002_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
H5010	002	0	1	04	01	H5010_002_0	7	5	2	1	Specialty Medications	110001		1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5010	002	0	1	04	01	H5010_002_0	7	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5010	002	0	1	04	01	H5010_002_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H5010	002	0	1	04	01	H5010_002_0	7	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5010	004	0	1	04	01	H5010_004_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5010	004	0	1	04	01	H5010_004_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5010	004	0	1	04	01	H5010_004_0	8	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
H5010	004	0	1	04	01	H5010_004_0	8	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
H5010	004	0	1	04	01	H5010_004_0	8	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5010	004	0	1	04	01	H5010_004_0	8	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5010	004	0	1	04	01	H5010_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H5010	004	0	1	04	01	H5010_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H5010	004	0	1	04	01	H5010_004_0	8	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5010	004	0	1	04	01	H5010_004_0	8	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5010	006	0	1	04	01	H5010_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H5010	006	0	1	04	01	H5010_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
H5010	006	0	1	04	01	H5010_006_0	5	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
H5010	006	0	1	04	01	H5010_006_0	5	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
H5010	006	0	1	04	01	H5010_006_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H5031	001	0	1	04	01	H5031_001_0	6	1	2	1	Generic	011000		2				Generic	111000000001010000000	31	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		10.00								5.00
H5031	001	0	1	04	01	H5031_001_0	6	4	2	1	Specialty	100011		1				Specialty	110000000001000000000	31										10										31	Specialty	2	1	Specialty	25										25										25	Specialty																					
H5031	001	0	1	04	01	H5031_001_0	6	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	31	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00									75.00		150.00								75.00
H5031	001	0	1	04	01	H5031_001_0	6	2	2	1	Preferred Brand	000011		2				Preferred Brand	111000000001010000000	31	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00									40.00		80.00								40.00
H5041	001	0	1	04	01	H5041_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5041	001	0	1	04	01	H5041_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5041	001	0	1	04	01	H5041_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5041	001	0	1	04	01	H5041_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5041	001	0	1	04	01	H5041_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5041	001	0	1	04	01	H5041_001_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5041	001	0	1	04	01	H5041_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5041	001	0	1	04	01	H5041_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5042	001	0	1	04	01	H5042_001_0	8	3	4	3	Tier 3 Formulary Preferred Brand	000001	1	2	2			Tier 3 Formulary Preferred Brand																							Tier 3 Formulary Preferred Brand			Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand																					
H5042	001	0	1	04	01	H5042_001_0	8	4	4	3	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2	2			Tier 4 Formulary Preferred Brand Diagnostic																							Tier 4 Formulary Preferred Brand Diagnostic			Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic																					
H5042	001	0	1	04	01	H5042_001_0	8	2	4	3	Tier 2 Formulary Generics	010000	1	2	1		1	Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H5042	001	0	1	04	01	H5042_001_0	8	1	4	3	Tier 1 Formulary Value Generics	010000	1	2	1		1	Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H5042	001	0	1	04	01	H5042_001_0	8	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H5042	001	0	1	04	01	H5042_001_0	8	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H5042	001	0	1	04	01	H5042_001_0	8	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5042	001	0	1	04	01	H5042_001_0	8	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5042	001	0	1	04	01	H5042_001_0	8	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H5042	001	0	1	04	01	H5042_001_0	8	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H5042	001	0	1	04	01	H5042_001_0	8	5	4	3	Tier 5 Formulary Non-Preferred Brand	100000	1	2	2			Tier 5 Formulary Non-Preferred Brand																							Tier 5 Formulary Non-Preferred Brand			Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand																					
H5042	001	0	1	04	01	H5042_001_0	8	6	4	3	Tier 6 Formulary Specialty	010010	1	1	2			Tier 6 Formulary Specialty																							Tier 6 Formulary Specialty			Tier 6 Formulary Specialty																						Tier 6 Formulary Specialty																					
H5042	005	0	1	04	01	H5042_005_0	8	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H5042	005	0	1	04	01	H5042_005_0	8	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5042	005	0	1	04	01	H5042_005_0	8	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5042	005	0	1	04	01	H5042_005_0	8	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H5042	005	0	1	04	01	H5042_005_0	8	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H5042	005	0	1	04	01	H5042_005_0	8	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H5042	007	0	1	04	01	H5042_007_0	8	1	4	3	Tier 1 Formulary Value Generics	010000	1	2	1		1	Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H5042	007	0	1	04	01	H5042_007_0	8	2	4	3	Tier 2 Formulary Generics	010000	1	2	1		1	Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H5042	007	0	1	04	01	H5042_007_0	8	3	4	3	Tier 3 Formulary Preferred Brand	000001	1	2	2			Tier 3 Formulary Preferred Brand																							Tier 3 Formulary Preferred Brand			Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand																					
H5042	007	0	1	04	01	H5042_007_0	8	4	4	3	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2	2			Tier 4 Formulary Preferred Brand Diagnostic																							Tier 4 Formulary Preferred Brand Diagnostic			Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic																					
H5042	007	0	1	04	01	H5042_007_0	8	5	4	3	Tier 5 Formulary Non-Preferred Brand	100000	1	2	2			Tier 5 Formulary Non-Preferred Brand																							Tier 5 Formulary Non-Preferred Brand			Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand																					
H5042	007	0	1	04	01	H5042_007_0	8	6	4	1	Tier 6 Formulary Specialty	010010	1	1				Tier 6 Formulary Specialty	100010010010100000000				30			30			30		30									31	Tier 6 Formulary Specialty	2	1	Tier 6 Formulary Specialty				30			30			30		30									30	Tier 6 Formulary Specialty																					
H5042	007	0	1	04	01	H5042_007_0	8	5	4	1	Tier 5 Formulary Non-Preferred Brand	100000	1	2				Tier 5 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 5 Formulary Non-Preferred Brand	2	2	Tier 5 Formulary Non-Preferred Brand																						Tier 5 Formulary Non-Preferred Brand				60.00	180.00		65.00	195.00		65.00		60.00	150.00								65.00
H5042	007	0	1	04	01	H5042_007_0	8	4	4	1	Tier 4 Formulary Preferred Brand Diagnostic	000001	1	2				Tier 4 Formulary Preferred Brand Diagnostic	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4 Formulary Preferred Brand Diagnostic	2	2	Tier 4 Formulary Preferred Brand Diagnostic																						Tier 4 Formulary Preferred Brand Diagnostic				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5042	007	0	1	04	01	H5042_007_0	8	6	4	3	Tier 6 Formulary Specialty	010010	1	1	2			Tier 6 Formulary Specialty																							Tier 6 Formulary Specialty			Tier 6 Formulary Specialty																						Tier 6 Formulary Specialty																					
H5042	007	0	1	04	01	H5042_007_0	8	2	4	1	Tier 2 Formulary Generics	010000	1	2				Tier 2 Formulary Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2 Formulary Generics	2	2	Tier 2 Formulary Generics																						Tier 2 Formulary Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00
H5042	007	0	1	04	01	H5042_007_0	8	1	4	1	Tier 1 Formulary Value Generics	010000	1	2				Tier 1 Formulary Value Generics	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1 Formulary Value Generics	2	2	Tier 1 Formulary Value Generics																						Tier 1 Formulary Value Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00
H5042	007	0	1	04	01	H5042_007_0	8	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2				Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3 Formulary Preferred Brand	2	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				30.00	90.00		35.00	105.00		35.00		30.00	70.00								35.00
H5050	004	0	1	01	01	H5050_004_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	45.00								15.00
H5050	004	0	1	01	01	H5050_004_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00		9.00	27.00								9.00
H5050	004	0	1	01	01	H5050_004_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010110000000	30	90								30		30								90	31	Non-Preferred	2	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																					
H5050	009	0	1	01	01	H5050_009_0	6	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	1	Preferred Brand	30	30								30		30	30								30	Preferred Brand																					
H5050	009	0	1	01	01	H5050_009_0	6	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
H5050	009	0	1	01	01	H5050_009_0	6	3	2	1	Non-Preferred	100100		2				Non-Preferred	111000000010110000000	30	90								30		30								90	31	Non-Preferred	2	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																					
H5050	012	0	1	01	01	H5050_012_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00		10.00	30.00								10.00
H5050	012	0	1	01	01	H5050_012_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	30.00								10.00
H5050	012	0	1	01	01	H5050_012_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010110000000	30	90								30		30								90	31	Non-Preferred	2	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																					
H5050	012	0	1	01	01	H5050_012_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00		10.00	30.00								10.00
H5050	012	0	1	01	01	H5050_012_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5050	012	0	1	01	01	H5050_012_0	6	3	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H5087	001	0	1	01	01	H5087_001_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H5087	001	0	1	01	01	H5087_001_0	12	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5087	001	0	1	01	01	H5087_001_0	12	4	4	3	Specialty Drugs	101101	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5087	001	0	1	01	01	H5087_001_0	12	3	4	3	Non-Preferred Drugs	100100	1	2	2			Non-Preferred Drugs																							Non-Preferred Drugs			Non-Preferred Drugs																						Non-Preferred Drugs																					
H5087	001	0	1	01	01	H5087_001_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5087	001	0	1	01	01	H5087_001_0	12	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5087	001	0	1	01	01	H5087_001_0	12	4	4	1	Specialty Drugs	101101	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H5087	001	0	1	01	01	H5087_001_0	12	3	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	111000000010110000000	30	90								30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs	80.00	160.00								80.00		80.00	160.00								80.00
H5087	002	0	1	01	01	H5087_002_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H5087	002	0	1	01	01	H5087_002_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5087	002	0	1	01	01	H5087_002_0	11	4	4	1	Specialty Drugs	101101	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H5087	002	0	1	01	01	H5087_002_0	11	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5087	002	0	1	01	01	H5087_002_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5087	002	0	1	01	01	H5087_002_0	11	3	4	3	Non-Preferred Drugs	100100	1	2	2			Non-Preferred Drugs																							Non-Preferred Drugs			Non-Preferred Drugs																						Non-Preferred Drugs																					
H5087	002	0	1	01	01	H5087_002_0	11	4	4	3	Specialty Drugs	101101	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5087	002	0	1	01	01	H5087_002_0	11	3	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	111000000010110000000	30	90								30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs	80.00	160.00								80.00		80.00	160.00								80.00
H5087	005	0	1	01	01	H5087_005_0	14	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	20.00								10.00		10.00	20.00								10.00
H5087	005	0	1	01	01	H5087_005_0	14	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5087	005	0	1	01	01	H5087_005_0	14	4	4	3	Specialty Drugs	101101	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5087	005	0	1	01	01	H5087_005_0	14	3	4	3	Non-Preferred Drugs	100100	1	2	2			Non-Preferred Drugs																							Non-Preferred Drugs			Non-Preferred Drugs																						Non-Preferred Drugs																					
H5087	005	0	1	01	01	H5087_005_0	14	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	20.00								10.00		10.00	20.00								10.00
H5087	005	0	1	01	01	H5087_005_0	14	3	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	111000000010110000000	30	90								30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs	80.00	160.00								80.00		80.00	160.00								80.00
H5087	005	0	1	01	01	H5087_005_0	14	4	4	1	Specialty Drugs	101101	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																					
H5087	005	0	1	01	01	H5087_005_0	14	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5106	013	0	1	04	01	H5106_013_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	013	0	1	04	01	H5106_013_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H5106	013	0	1	04	01	H5106_013_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5106	013	0	1	04	01	H5106_013_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H5106	014	0	1	04	01	H5106_014_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	014	0	1	04	01	H5106_014_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H5106	014	0	1	04	01	H5106_014_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H5106	014	0	1	04	01	H5106_014_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5106	014	0	1	04	01	H5106_014_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	014	0	1	04	01	H5106_014_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5106	014	0	1	04	01	H5106_014_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5106	014	0	1	04	01	H5106_014_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5106	015	0	1	04	01	H5106_015_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5106	015	0	1	04	01	H5106_015_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	015	0	1	04	01	H5106_015_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H5106	015	0	1	04	01	H5106_015_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H5106	016	0	1	04	01	H5106_016_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	016	0	1	04	01	H5106_016_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5106	016	0	1	04	01	H5106_016_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H5106	016	0	1	04	01	H5106_016_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H5106	016	0	1	04	01	H5106_016_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H5106	016	0	1	04	01	H5106_016_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5106	016	0	1	04	01	H5106_016_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5106	016	0	1	04	01	H5106_016_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5144	001	0	1	04	01	H5144_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5144	001	0	1	04	01	H5144_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5144	001	0	1	04	01	H5144_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5144	001	0	1	04	01	H5144_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5144	001	0	1	04	01	H5144_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5151	002	0	1	01	01	H5151_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5151	002	0	1	01	01	H5151_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H5151	002	0	1	01	01	H5151_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H5151	002	0	1	01	01	H5151_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
H5151	002	0	1	01	01	H5151_002_0	6	4	4	3	Specialty	010001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5151	002	0	1	01	01	H5151_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5151	002	0	1	01	01	H5151_002_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H5151	002	0	1	01	01	H5151_002_0	6	4	4	1	Specialty	010001	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	20									20		20									20	Specialty																					
H5179	001	0	1	09	04	H5179_001_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H5179	001	0	1	09	04	H5179_001_0	4	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00
H5179	001	0	1	09	04	H5179_001_0	4	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
H5179	001	0	1	09	04	H5179_001_0	4	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
H5179	002	0	1	09	04	H5179_002_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H5179	002	0	1	09	04	H5179_002_0	4	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
H5179	002	0	1	09	04	H5179_002_0	4	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00
H5179	002	0	1	09	04	H5179_002_0	4	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
H5179	006	0	1	09	04	H5179_006_0	6	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
H5179	006	0	1	09	04	H5179_006_0	6	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
H5179	006	0	1	09	04	H5179_006_0	6	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00
H5179	006	0	1	09	04	H5179_006_0	6	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
H5189	001	0	1	01	01	H5189_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H5189	001	0	1	01	01	H5189_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H5189	001	0	1	01	01	H5189_001_0	7	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5189	001	0	1	01	01	H5189_001_0	7	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H5189	002	0	1	01	01	H5189_002_0	7	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5189	002	0	1	01	01	H5189_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H5189	002	0	1	01	01	H5189_002_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H5189	002	0	1	01	01	H5189_002_0	7	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H5189	002	0	1	01	01	H5189_002_0	7	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H5189	002	0	1	01	01	H5189_002_0	7	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H5189	002	0	1	01	01	H5189_002_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5189	002	0	1	01	01	H5189_002_0	7	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5211	002	0	1	02	01	H5211_002_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00
H5211	002	0	1	02	01	H5211_002_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	22.00	66.00								22.00			66.00								22.00
H5211	002	0	1	02	01	H5211_002_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	34	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H5211	002	0	1	02	01	H5211_002_0	9	4	4	1	Tier 4	000001	1	1				Tier 4	110000000010100000000	30									30		30									34	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H5211	004	0	1	02	01	H5211_004_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00
H5211	004	0	1	02	01	H5211_004_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	22.00	66.00								22.00			66.00								22.00
H5211	004	0	1	02	01	H5211_004_0	9	4	4	1	Tier 4	000001	1	1				Tier 4	110000000010100000000	30									30		30									34	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H5211	004	0	1	02	01	H5211_004_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	34	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H5211	005	0	1	02	01	H5211_005_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00
H5211	005	0	1	02	01	H5211_005_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	34	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00
H5211	005	0	1	02	01	H5211_005_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	22.00	66.00								22.00			66.00								22.00
H5211	005	0	1	02	01	H5211_005_0	8	4	4	1	Tier 4	000001	1	1				Tier 4	110000000010100000000	30									30		30									34	Tier 4	2	1	Tier 4	33									33		33									33	Tier 4																					
H5214	003	0	1	04	01	H5214_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5214	003	0	1	04	01	H5214_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5214	003	0	1	04	01	H5214_003_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5214	003	0	1	04	01	H5214_003_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5214	003	0	1	04	01	H5214_003_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5214	003	0	1	04	01	H5214_003_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5214	003	0	1	04	01	H5214_003_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5214	003	0	1	04	01	H5214_003_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5214	004	0	1	04	01	H5214_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5214	004	0	1	04	01	H5214_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H5214	004	0	1	04	01	H5214_004_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H5214	004	0	1	04	01	H5214_004_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5214	004	0	1	04	01	H5214_004_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5214	004	0	1	04	01	H5214_004_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H5214	004	0	1	04	01	H5214_004_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H5214	004	0	1	04	01	H5214_004_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5215	002	0	1	04	01	H5215_002_0	8	3	4	1	Formulary Non-Preferred Brand	100100	1	2				Formulary Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00
H5215	002	0	1	04	01	H5215_002_0	8	4	4	1	Specialty Products	001001	1	1				Specialty Products	110000000010000000000	31									31											31	Specialty Products	2	1	Specialty Products	25									25											25	Specialty Products																					
H5215	002	0	1	04	01	H5215_002_0	8	2	4	1	Formulary Preferred Brand	010001	1	2				Formulary Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00
H5215	002	0	1	04	01	H5215_002_0	8	1	4	1	Formulary Generic	011000	1	2				Formulary Generic	111000000010110000000	31	90								31		31								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	19.00								7.00		7.00	19.00								7.00
H5215	002	0	1	04	01	H5215_002_0	8	1	4	3	Formulary Generic	011000	1	2	1		1	Formulary Generic	111000000010110000000	31	90								31		31								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	24.00								9.00		9.00	24.00								9.00
H5215	002	0	1	04	01	H5215_002_0	8	2	4	3	Formulary Preferred Brand	010001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
H5215	002	0	1	04	01	H5215_002_0	8	3	4	3	Formulary Non-Preferred Brand	100100	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
H5215	002	0	1	04	01	H5215_002_0	8	4	4	3	Specialty Products	001001	1	1	2			Specialty Products																							Specialty Products			Specialty Products																						Specialty Products																					
H5215	005	0	1	04	01	H5215_005_0	8	4	4	1	Specialty Products	001001	1	1				Specialty Products	110000000010000000000	31									31											31	Specialty Products	2	1	Specialty Products	25									25											25	Specialty Products																					
H5215	005	0	1	04	01	H5215_005_0	8	3	4	1	Formulary Non-Preferred Brand	100100	1	2				Formulary Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00
H5215	005	0	1	04	01	H5215_005_0	8	2	4	1	Formulary Preferred Brand	010001	1	2				Formulary Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00
H5215	005	0	1	04	01	H5215_005_0	8	1	4	1	Formulary Generic	011000	1	2				Formulary Generic	111000000010110000000	31	90								31		31								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	19.00								7.00		7.00	19.00								7.00
H5215	005	0	1	04	01	H5215_005_0	8	1	4	3	Formulary Generic	011000	1	2	1		1	Formulary Generic	111000000010110000000	31	90								31		31								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	24.00								9.00		9.00	24.00								9.00
H5215	005	0	1	04	01	H5215_005_0	8	2	4	3	Formulary Preferred Brand	010001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
H5215	005	0	1	04	01	H5215_005_0	8	4	4	3	Specialty Products	001001	1	1	2			Specialty Products																							Specialty Products			Specialty Products																						Specialty Products																					
H5215	005	0	1	04	01	H5215_005_0	8	3	4	3	Formulary Non-Preferred Brand	100100	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
H5215	007	0	1	04	01	H5215_007_0	6	1	3	1	Basic Alternative	001001		2				Basic Alternative	111000000010110000000	31	90								31		31								90	31	Basic Alternative	2	2	Basic Alternative																						Basic Alternative	0.00	0.00								0.00		0.00	0.00								0.00
H5215	007	0	1	04	01	H5215_007_0	6	3	3	1	Basic Alternative	100100		2				Basic Alternative	111000000010110000000	31	90								31		31								90	31	Basic Alternative	2	2	Basic Alternative																						Basic Alternative	94.00	282.00								94.00		94.00	282.00								94.00
H5215	007	0	1	04	01	H5215_007_0	6	2	3	1	Basic Alternative	010001		2				Basic Alternative	111000000010110000000	31	90								31		31								90	31	Basic Alternative	2	2	Basic Alternative																						Basic Alternative	40.00	120.00								40.00		40.00	120.00								40.00
H5215	007	0	1	04	01	H5215_007_0	6	4	3	1	Basic Alternative	001001		1				Basic Alternative	110000000010000000000	31									31											31	Basic Alternative	2	1	Basic Alternative	25									25											25	Basic Alternative																					
H5215	008	0	1	04	01	H5215_008_0	7	3	4	1	Formulary Non-Preferred Brand	100100	1	2				Formulary Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00
H5215	008	0	1	04	01	H5215_008_0	7	4	4	1	Specialty Products	001001	1	1				Specialty Products	110000000010000000000	31									31											31	Specialty Products	2	1	Specialty Products	25									25											25	Specialty Products																					
H5215	008	0	1	04	01	H5215_008_0	7	2	4	1	Formulary Preferred Brand	010001	1	2				Formulary Preferred Brand	111000000010110000000	31	90								31		31								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00
H5215	008	0	1	04	01	H5215_008_0	7	1	4	1	Formulary Generic	011000	1	2				Formulary Generic	111000000010110000000	31	90								31		31								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	19.00								7.00		7.00	19.00								7.00
H5216	001	0	1	04	01	H5216_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5216	001	0	1	04	01	H5216_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	186.00								62.00					62.00	155.00		62.00	186.00		62.00
H5216	001	0	1	04	01	H5216_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5216	001	0	1	04	01	H5216_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5216	001	0	1	04	01	H5216_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5216	001	0	1	04	01	H5216_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	186.00								62.00					62.00	155.00		62.00	186.00		62.00
H5216	001	0	1	04	01	H5216_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5216	001	0	1	04	01	H5216_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5216	003	0	1	04	01	H5216_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5216	003	0	1	04	01	H5216_003_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5216	003	0	1	04	01	H5216_003_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5216	003	0	1	04	01	H5216_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5216	003	0	1	04	01	H5216_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5216	003	0	1	04	01	H5216_003_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5216	003	0	1	04	01	H5216_003_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5216	003	0	1	04	01	H5216_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5227	001	0	1	09	04	H5227_001_0	9	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	73.00	219.00								73.00			219.00								73.00
H5227	001	0	1	09	04	H5227_001_0	9	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H5227	001	0	1	09	04	H5227_001_0	9	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5227	001	0	1	09	04	H5227_001_0	9	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5227	002	0	1	09	04	H5227_002_0	5	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	73.00	219.00								73.00			219.00								73.00
H5227	002	0	1	09	04	H5227_002_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H5227	002	0	1	09	04	H5227_002_0	5	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5227	002	0	1	09	04	H5227_002_0	5	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5227	004	0	1	09	04	H5227_004_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5227	004	0	1	09	04	H5227_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	74.00								37.00			74.00								37.00
H5227	004	0	1	09	04	H5227_004_0	5	3	4	1	Non Preferred Generic/Non Preferred Brand	100100	1	2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	70.00	210.00								70.00			210.00								70.00
H5227	004	0	1	09	04	H5227_004_0	5	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5227	004	0	1	09	04	H5227_004_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5227	004	0	1	09	04	H5227_004_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5227	004	0	1	09	04	H5227_004_0	5	3	4	3	Non Preferred Generic/Non Preferred Brand	100100	1	2	2			Non Preferred Generic/Non Preferred Brand																							Non Preferred Generic/Non Preferred Brand			Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand																					
H5227	004	0	1	09	04	H5227_004_0	5	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H5227	005	0	1	09	04	H5227_005_0	6	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5227	005	0	1	09	04	H5227_005_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H5227	005	0	1	09	04	H5227_005_0	6	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	73.00	219.00								73.00			219.00								73.00
H5227	005	0	1	09	04	H5227_005_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5253	004	0	1	02	01	H5253_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5253	004	0	1	02	01	H5253_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H5253	004	0	1	02	01	H5253_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5253	004	0	1	02	01	H5253_004_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5253	007	0	1	02	01	H5253_007_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5253	007	0	1	02	01	H5253_007_0	9	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H5253	007	0	1	02	01	H5253_007_0	9	2	4	1	Preferred Brnad	000001	1	2				Preferred Brnad	111000000010000010010	31	90								31					90			90			31	Preferred Brnad	2	2	Preferred Brnad																						Preferred Brnad	41.00	123.00								41.00						113.00			123.00		41.00
H5253	007	0	1	02	01	H5253_007_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5253	011	0	1	02	01	H5253_011_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	58.00	174.00								58.00						164.00			174.00		58.00
H5253	011	0	1	02	01	H5253_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00						74.00			84.00		28.00
H5253	011	0	1	02	01	H5253_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H5253	011	0	1	02	01	H5253_011_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5253	027	0	1	02	01	H5253_027_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H5253	027	0	1	02	01	H5253_027_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5253	027	0	1	02	01	H5253_027_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H5253	027	0	1	02	01	H5253_027_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H5253	027	0	1	02	01	H5253_027_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5253	027	0	1	02	01	H5253_027_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5253	027	0	1	02	01	H5253_027_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5253	027	0	1	02	01	H5253_027_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5262	001	0	1	01	01	H5262_001_0	4	4	3	1	Tier 4 - Specialty High Cost Drugs	010010		1				Tier 4 - Specialty High Cost Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty High Cost Drugs	2	1	Tier 4 - Specialty High Cost Drugs	33									33											33	Tier 4 - Specialty High Cost Drugs																					
H5262	001	0	1	01	01	H5262_001_0	4	3	3	1	Tier 3 - Formulary Non-Preferred Brand Drugs	100000		2				Tier 3 - Formulary Non-Preferred Brand Drugs	111000000010000000000	30	90								30											31	Tier 3 - Formulary Non-Preferred Brand Drugs	2	2	Tier 3 - Formulary Non-Preferred Brand Drugs																						Tier 3 - Formulary Non-Preferred Brand Drugs	87.00	261.00								87.00											87.00
H5262	001	0	1	01	01	H5262_001_0	4	1	3	1	Tier 1 - Generic Drugs	010000		2				Tier 1 - Generic Drugs	111000000010000000000	30	90								30											31	Tier 1 - Generic Drugs	2	2	Tier 1 - Generic Drugs																						Tier 1 - Generic Drugs	6.00	18.00								6.00											6.00
H5262	001	0	1	01	01	H5262_001_0	4	2	3	1	Tier 2 - Formulary Preferred Brand Drugs	000001		2				Tier 2 - Formulary Preferred Brand Drugs	111000000010000000000	30	90								30											31	Tier 2 - Formulary Preferred Brand Drugs	2	2	Tier 2 - Formulary Preferred Brand Drugs																						Tier 2 - Formulary Preferred Brand Drugs	28.00	84.00								28.00											28.00
H5262	003	0	1	01	01	H5262_003_0	4	4	3	1	Tier 4 - Specialty High Cost Drugs	010010		1				Tier 4 - Specialty High Cost Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty High Cost Drugs	2	1	Tier 4 - Specialty High Cost Drugs	33									33											33	Tier 4 - Specialty High Cost Drugs																					
H5262	003	0	1	01	01	H5262_003_0	4	3	3	1	Tier 3 - Formulary Non-Preferred Brand Drugs	100000		2				Tier 3 - Formulary Non-Preferred Brand Drugs	111000000010000000000	30	90								30											31	Tier 3 - Formulary Non-Preferred Brand Drugs	2	2	Tier 3 - Formulary Non-Preferred Brand Drugs																						Tier 3 - Formulary Non-Preferred Brand Drugs	87.00	261.00								87.00											87.00
H5262	003	0	1	01	01	H5262_003_0	4	1	3	1	Tier 1 - Generic Drugs	010000		2				Tier 1 - Generic Drugs	111000000010000000000	30	90								30											31	Tier 1 - Generic Drugs	2	2	Tier 1 - Generic Drugs																						Tier 1 - Generic Drugs	7.00	21.00								7.00											7.00
H5262	003	0	1	01	01	H5262_003_0	4	2	3	1	Tier 2 - Formulary Preferred Brand Drugs	000001		2				Tier 2 - Formulary Preferred Brand Drugs	111000000010000000000	30	90								30											31	Tier 2 - Formulary Preferred Brand Drugs	2	2	Tier 2 - Formulary Preferred Brand Drugs																						Tier 2 - Formulary Preferred Brand Drugs	29.00	87.00								29.00											29.00
H5270	001	0	1	01	01	H5270_001_0	6	4	4	1	Specialty- Tier 4	010010	1	1				Specialty- Tier 4	111000000001110000000	31	90									10	31								90	31	Specialty- Tier 4	2	1	Specialty- Tier 4	33	33									33	33	33								33	Specialty- Tier 4																					
H5270	001	0	1	01	01	H5270_001_0	6	1	4	1	Generic- Tier 1	010000	1	2				Generic- Tier 1	111000000001110000000	31	90									10	31								90	31	Generic- Tier 1	2	2	Generic- Tier 1																						Generic- Tier 1	3.50	10.50									3.50	3.50	10.50								3.50
H5270	001	0	1	01	01	H5270_001_0	6	3	4	1	Non-Preferred Brand-Tier 3	100000	1	2				Non-Preferred Brand-Tier 3	111000000001110000000	31	90									10	31								90	31	Non-Preferred Brand-Tier 3	2	2	Non-Preferred Brand-Tier 3																						Non-Preferred Brand-Tier 3	45.00	135.00									45.00	45.00	135.00								45.00
H5270	001	0	1	01	01	H5270_001_0	6	2	4	1	Preferred Brand - Tier 2	000001	1	2				Preferred Brand - Tier 2	111000000001110000000	31	90									10	31								90	31	Preferred Brand - Tier 2	2	2	Preferred Brand - Tier 2																						Preferred Brand - Tier 2	25.00	75.00									25.00	25.00	75.00								25.00
H5291	001	0	1	01	01	H5291_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5291	001	0	1	01	01	H5291_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5291	001	0	1	01	01	H5291_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5291	001	0	1	01	01	H5291_001_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5291	001	0	1	01	01	H5291_001_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5291	001	0	1	01	01	H5291_001_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5291	001	0	1	01	01	H5291_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5291	001	0	1	01	01	H5291_001_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5294	001	0	1	01	01	H5294_001_0	7	4	4	1	Injectable	000001	1	2				Injectable	111000000010010000000	30	90								30										90	31	Injectable	2	2	Injectable																						Injectable	45.00	135.00								45.00			135.00								45.00
H5294	001	0	1	01	01	H5294_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	94.00	282.00								94.00			282.00								94.00
H5294	001	0	1	01	01	H5294_001_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00			135.00								45.00
H5294	001	0	1	01	01	H5294_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5302	003	0	1	02	01	H5302_003_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H5302	003	0	1	02	01	H5302_003_0	6	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H5302	003	0	1	02	01	H5302_003_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5302	003	0	1	02	01	H5302_003_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H5302	003	0	1	02	01	H5302_003_0	6	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H5302	003	0	1	02	01	H5302_003_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5302	003	0	1	02	01	H5302_003_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H5302	003	0	1	02	01	H5302_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	68.00								34.00			68.00								34.00
H5302	004	0	1	02	01	H5302_004_0	7	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H5302	004	0	1	02	01	H5302_004_0	7	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H5302	004	0	1	02	01	H5302_004_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5302	004	0	1	02	01	H5302_004_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H5302	004	0	1	02	01	H5302_004_0	7	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H5302	004	0	1	02	01	H5302_004_0	7	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5302	004	0	1	02	01	H5302_004_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H5302	004	0	1	02	01	H5302_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	68.00								34.00			68.00								34.00
H5304	006	0	1	09	04	H5304_006_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5304	006	0	1	09	04	H5304_006_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5304	006	0	1	09	04	H5304_006_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5304	006	0	1	09	04	H5304_006_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5304	006	0	1	09	04	H5304_006_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5304	006	0	1	09	04	H5304_006_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5304	006	0	1	09	04	H5304_006_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5304	006	0	1	09	04	H5304_006_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5304	006	0	1	09	04	H5304_006_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5304	006	0	1	09	04	H5304_006_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5304	007	0	1	09	04	H5304_007_0	10	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5304	007	0	1	09	04	H5304_007_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5304	007	0	1	09	04	H5304_007_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5304	007	0	1	09	04	H5304_007_0	10	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5304	007	0	1	09	04	H5304_007_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5304	007	0	1	09	04	H5304_007_0	10	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5304	007	0	1	09	04	H5304_007_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5304	007	0	1	09	04	H5304_007_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5304	007	0	1	09	04	H5304_007_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5304	007	0	1	09	04	H5304_007_0	10	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5378	004	0	1	04	01	H5378_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5378	004	0	1	04	01	H5378_004_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5378	004	0	1	04	01	H5378_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5378	004	0	1	04	01	H5378_004_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5378	004	0	1	04	01	H5378_004_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5378	004	0	1	04	01	H5378_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5378	004	0	1	04	01	H5378_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5378	004	0	1	04	01	H5378_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5378	005	0	1	04	01	H5378_005_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5378	005	0	1	04	01	H5378_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5378	005	0	1	04	01	H5378_005_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5378	005	0	1	04	01	H5378_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5378	005	0	1	04	01	H5378_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5378	005	0	1	04	01	H5378_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5378	005	0	1	04	01	H5378_005_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5378	005	0	1	04	01	H5378_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5378	006	0	1	04	01	H5378_006_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5378	006	0	1	04	01	H5378_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5378	006	0	1	04	01	H5378_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5378	006	0	1	04	01	H5378_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5378	006	0	1	04	01	H5378_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5378	006	0	1	04	01	H5378_006_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5378	006	0	1	04	01	H5378_006_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5378	006	0	1	04	01	H5378_006_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5402	007	0	1	01	01	H5402_007_0	6	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	007	0	1	01	01	H5402_007_0	6	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	007	0	1	01	01	H5402_007_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	007	0	1	01	01	H5402_007_0	6	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	007	0	1	01	01	H5402_007_0	6	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	007	0	1	01	01	H5402_007_0	6	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	007	0	1	01	01	H5402_007_0	6	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	007	0	1	01	01	H5402_007_0	6	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	007	0	1	01	01	H5402_007_0	6	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	007	0	1	01	01	H5402_007_0	6	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	007	0	1	01	01	H5402_007_0	6	3	4	3	Tier 3	001101	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5402	007	0	1	01	01	H5402_007_0	6	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	010	0	1	01	01	H5402_010_0	6	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	010	0	1	01	01	H5402_010_0	6	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	010	0	1	01	01	H5402_010_0	6	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	010	0	1	01	01	H5402_010_0	6	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	010	0	1	01	01	H5402_010_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	010	0	1	01	01	H5402_010_0	6	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	010	0	1	01	01	H5402_010_0	6	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	010	0	1	01	01	H5402_010_0	6	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	010	0	1	01	01	H5402_010_0	6	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	010	0	1	01	01	H5402_010_0	6	3	4	3	Tier 3	001101	3	2	1		1	Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	010	0	1	01	01	H5402_010_0	6	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	010	0	1	01	01	H5402_010_0	6	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	032	0	1	01	01	H5402_032_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	032	0	1	01	01	H5402_032_0	6	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	032	0	1	01	01	H5402_032_0	6	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	032	0	1	01	01	H5402_032_0	6	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	032	0	1	01	01	H5402_032_0	6	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	032	0	1	01	01	H5402_032_0	6	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	032	0	1	01	01	H5402_032_0	6	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	032	0	1	01	01	H5402_032_0	6	3	4	3	Tier 3	001101	3	2	1		1	Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	032	0	1	01	01	H5402_032_0	6	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	032	0	1	01	01	H5402_032_0	6	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	032	0	1	01	01	H5402_032_0	6	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	032	0	1	01	01	H5402_032_0	6	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	034	0	1	01	01	H5402_034_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	034	0	1	01	01	H5402_034_0	6	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	034	0	1	01	01	H5402_034_0	6	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	034	0	1	01	01	H5402_034_0	6	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	65.00									65.00											65.00
H5402	034	0	1	01	01	H5402_034_0	6	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	034	0	1	01	01	H5402_034_0	6	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	035	0	1	01	01	H5402_035_0	9	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	035	0	1	01	01	H5402_035_0	9	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	035	0	1	01	01	H5402_035_0	9	3	4	3	Tier 3	001101	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5402	035	0	1	01	01	H5402_035_0	9	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	035	0	1	01	01	H5402_035_0	9	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	035	0	1	01	01	H5402_035_0	9	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	035	0	1	01	01	H5402_035_0	9	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	035	0	1	01	01	H5402_035_0	9	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	035	0	1	01	01	H5402_035_0	9	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	035	0	1	01	01	H5402_035_0	9	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	035	0	1	01	01	H5402_035_0	9	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	035	0	1	01	01	H5402_035_0	9	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	036	0	1	01	01	H5402_036_0	7	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	036	0	1	01	01	H5402_036_0	7	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	036	0	1	01	01	H5402_036_0	7	3	4	3	Tier 3	001101	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5402	036	0	1	01	01	H5402_036_0	7	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	036	0	1	01	01	H5402_036_0	7	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	036	0	1	01	01	H5402_036_0	7	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	036	0	1	01	01	H5402_036_0	7	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	036	0	1	01	01	H5402_036_0	7	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	036	0	1	01	01	H5402_036_0	7	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	036	0	1	01	01	H5402_036_0	7	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	036	0	1	01	01	H5402_036_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	036	0	1	01	01	H5402_036_0	7	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	038	0	1	01	01	H5402_038_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	038	0	1	01	01	H5402_038_0	6	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	038	0	1	01	01	H5402_038_0	6	6	4	3	Tier 6 - Specialty Medications	100110	3	1	2			Tier 6 - Specialty Medications																							Tier 6 - Specialty Medications			Tier 6 - Specialty Medications																						Tier 6 - Specialty Medications																					
H5402	038	0	1	01	01	H5402_038_0	6	5	4	3	Tier 5	100100	3	2	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
H5402	038	0	1	01	01	H5402_038_0	6	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5402	038	0	1	01	01	H5402_038_0	6	3	4	3	Tier 3	001101	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5402	038	0	1	01	01	H5402_038_0	6	2	4	3	Tier 2 - Health Management	000101	3	2	1		1	Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	038	0	1	01	01	H5402_038_0	6	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	038	0	1	01	01	H5402_038_0	6	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	038	0	1	01	01	H5402_038_0	6	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	038	0	1	01	01	H5402_038_0	6	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	50.00									50.00											50.00
H5402	038	0	1	01	01	H5402_038_0	6	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	039	0	1	01	01	H5402_039_0	7	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	039	0	1	01	01	H5402_039_0	7	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	039	0	1	01	01	H5402_039_0	7	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	72.00									72.00											72.00
H5402	039	0	1	01	01	H5402_039_0	7	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	039	0	1	01	01	H5402_039_0	7	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	039	0	1	01	01	H5402_039_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5402	041	0	1	01	01	H5402_041_0	8	6	4	1	Tier 6 - Specialty Medications	100110	3	1				Tier 6 - Specialty Medications	110000000010000000000	30									30											31	Tier 6 - Specialty Medications	2	1	Tier 6 - Specialty Medications	33									33											33	Tier 6 - Specialty Medications																					
H5402	041	0	1	01	01	H5402_041_0	8	2	4	1	Tier 2 - Health Management	000101	3	2				Tier 2 - Health Management	111000000010110000000	30	90								30		30								90	31	Tier 2 - Health Management	2	2	Tier 2 - Health Management																						Tier 2 - Health Management	10.00	30.00								10.00		10.00	20.00								10.00
H5402	041	0	1	01	01	H5402_041_0	8	3	4	1	Tier 3	001101	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00
H5402	041	0	1	01	01	H5402_041_0	8	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	65.00									65.00											65.00
H5402	041	0	1	01	01	H5402_041_0	8	5	4	1	Tier 5	100100	3	2				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
H5402	041	0	1	01	01	H5402_041_0	8	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00
H5404	001	0	1	01	01	H5404_001_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	001	0	1	01	01	H5404_001_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	001	0	1	01	01	H5404_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	001	0	1	01	01	H5404_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	002	0	1	01	01	H5404_002_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	002	0	1	01	01	H5404_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	002	0	1	01	01	H5404_002_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	002	0	1	01	01	H5404_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	003	0	1	01	01	H5404_003_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	003	0	1	01	01	H5404_003_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	003	0	1	01	01	H5404_003_0	8	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	003	0	1	01	01	H5404_003_0	8	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	004	0	1	01	01	H5404_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	004	0	1	01	01	H5404_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	004	0	1	01	01	H5404_004_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	004	0	1	01	01	H5404_004_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	013	0	1	01	01	H5404_013_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	013	0	1	01	01	H5404_013_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	013	0	1	01	01	H5404_013_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	013	0	1	01	01	H5404_013_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	016	0	1	01	01	H5404_016_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	016	0	1	01	01	H5404_016_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	016	0	1	01	01	H5404_016_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	016	0	1	01	01	H5404_016_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	022	0	1	01	01	H5404_022_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	022	0	1	01	01	H5404_022_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	022	0	1	01	01	H5404_022_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	022	0	1	01	01	H5404_022_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	025	0	1	01	01	H5404_025_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	025	0	1	01	01	H5404_025_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	025	0	1	01	01	H5404_025_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	025	0	1	01	01	H5404_025_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	028	0	1	01	01	H5404_028_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	028	0	1	01	01	H5404_028_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	028	0	1	01	01	H5404_028_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	028	0	1	01	01	H5404_028_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	034	0	1	01	01	H5404_034_0	8	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	034	0	1	01	01	H5404_034_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	034	0	1	01	01	H5404_034_0	8	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	034	0	1	01	01	H5404_034_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	037	0	1	01	01	H5404_037_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	037	0	1	01	01	H5404_037_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	037	0	1	01	01	H5404_037_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	037	0	1	01	01	H5404_037_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	043	0	1	01	01	H5404_043_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	043	0	1	01	01	H5404_043_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	043	0	1	01	01	H5404_043_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	043	0	1	01	01	H5404_043_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	053	0	1	01	01	H5404_053_0	8	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	053	0	1	01	01	H5404_053_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	053	0	1	01	01	H5404_053_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	053	0	1	01	01	H5404_053_0	8	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	086	0	1	02	01	H5404_086_0	10	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	086	0	1	02	01	H5404_086_0	10	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	086	0	1	02	01	H5404_086_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	086	0	1	02	01	H5404_086_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	094	0	1	01	01	H5404_094_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	094	0	1	01	01	H5404_094_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5404	094	0	1	01	01	H5404_094_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	094	0	1	01	01	H5404_094_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	114	0	1	01	01	H5404_114_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5404	114	0	1	01	01	H5404_114_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5404	114	0	1	01	01	H5404_114_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5404	114	0	1	01	01	H5404_114_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5407	001	0	1	02	01	H5407_001_0	5	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	001	0	1	02	01	H5407_001_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	001	0	1	02	01	H5407_001_0	5	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	001	0	1	02	01	H5407_001_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	001	0	1	02	01	H5407_001_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	001	0	1	02	01	H5407_001_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	001	0	1	02	01	H5407_001_0	5	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	001	0	1	02	01	H5407_001_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	001	0	1	02	01	H5407_001_0	5	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	001	0	1	02	01	H5407_001_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	001	0	1	02	01	H5407_001_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	001	0	1	02	01	H5407_001_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	004	0	1	02	01	H5407_004_0	4	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	004	0	1	02	01	H5407_004_0	4	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	004	0	1	02	01	H5407_004_0	4	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	004	0	1	02	01	H5407_004_0	4	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	004	0	1	02	01	H5407_004_0	4	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	004	0	1	02	01	H5407_004_0	4	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	004	0	1	02	01	H5407_004_0	4	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	004	0	1	02	01	H5407_004_0	4	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	004	0	1	02	01	H5407_004_0	4	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	004	0	1	02	01	H5407_004_0	4	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	004	0	1	02	01	H5407_004_0	4	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	004	0	1	02	01	H5407_004_0	4	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	005	0	1	02	01	H5407_005_0	5	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	005	0	1	02	01	H5407_005_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	005	0	1	02	01	H5407_005_0	5	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	005	0	1	02	01	H5407_005_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	005	0	1	02	01	H5407_005_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	005	0	1	02	01	H5407_005_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	005	0	1	02	01	H5407_005_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	005	0	1	02	01	H5407_005_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	005	0	1	02	01	H5407_005_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	005	0	1	02	01	H5407_005_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	005	0	1	02	01	H5407_005_0	5	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	005	0	1	02	01	H5407_005_0	5	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	006	0	1	02	01	H5407_006_0	4	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	006	0	1	02	01	H5407_006_0	4	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	006	0	1	02	01	H5407_006_0	4	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	006	0	1	02	01	H5407_006_0	4	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	006	0	1	02	01	H5407_006_0	4	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	006	0	1	02	01	H5407_006_0	4	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	006	0	1	02	01	H5407_006_0	4	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	006	0	1	02	01	H5407_006_0	4	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	006	0	1	02	01	H5407_006_0	4	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	006	0	1	02	01	H5407_006_0	4	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	006	0	1	02	01	H5407_006_0	4	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	006	0	1	02	01	H5407_006_0	4	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	007	0	1	02	01	H5407_007_0	4	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	007	0	1	02	01	H5407_007_0	4	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	007	0	1	02	01	H5407_007_0	4	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	007	0	1	02	01	H5407_007_0	4	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	007	0	1	02	01	H5407_007_0	4	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	007	0	1	02	01	H5407_007_0	4	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	007	0	1	02	01	H5407_007_0	4	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	007	0	1	02	01	H5407_007_0	4	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	007	0	1	02	01	H5407_007_0	4	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	007	0	1	02	01	H5407_007_0	4	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	007	0	1	02	01	H5407_007_0	4	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	007	0	1	02	01	H5407_007_0	4	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	009	0	1	02	01	H5407_009_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	009	0	1	02	01	H5407_009_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	009	0	1	02	01	H5407_009_0	5	5	4	1	Tier 5 - Brands	000010	3	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	65.00	195.00								65.00			195.00								65.00
H5407	009	0	1	02	01	H5407_009_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	009	0	1	02	01	H5407_009_0	5	1	4	3	Tier 1 - Preferred Generics	001000	3	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	009	0	1	02	01	H5407_009_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	009	0	1	02	01	H5407_009_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	009	0	1	02	01	H5407_009_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	009	0	1	02	01	H5407_009_0	5	5	4	3	Tier 5 - Brands	000010	3	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	009	0	1	02	01	H5407_009_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	009	0	1	02	01	H5407_009_0	5	1	4	1	Tier 1 - Preferred Generics	001000	3	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	009	0	1	02	01	H5407_009_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	014	0	1	02	01	H5407_014_0	5	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	014	0	1	02	01	H5407_014_0	5	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	014	0	1	02	01	H5407_014_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	014	0	1	02	01	H5407_014_0	5	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	014	0	1	02	01	H5407_014_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	014	0	1	02	01	H5407_014_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	014	0	1	02	01	H5407_014_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	014	0	1	02	01	H5407_014_0	5	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	014	0	1	02	01	H5407_014_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	014	0	1	02	01	H5407_014_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	014	0	1	02	01	H5407_014_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	014	0	1	02	01	H5407_014_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	015	0	1	02	01	H5407_015_0	5	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	015	0	1	02	01	H5407_015_0	5	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	015	0	1	02	01	H5407_015_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	015	0	1	02	01	H5407_015_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	015	0	1	02	01	H5407_015_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	015	0	1	02	01	H5407_015_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	015	0	1	02	01	H5407_015_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	015	0	1	02	01	H5407_015_0	5	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	015	0	1	02	01	H5407_015_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	015	0	1	02	01	H5407_015_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	015	0	1	02	01	H5407_015_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	015	0	1	02	01	H5407_015_0	5	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	016	0	1	02	01	H5407_016_0	5	5	4	1	Tier 5 - Brands	000010	1	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	60.00	180.00								60.00			180.00								60.00
H5407	016	0	1	02	01	H5407_016_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	016	0	1	02	01	H5407_016_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	016	0	1	02	01	H5407_016_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	016	0	1	02	01	H5407_016_0	5	1	4	1	Tier 1 - Preferred Generics	001000	1	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	016	0	1	02	01	H5407_016_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	016	0	1	02	01	H5407_016_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	016	0	1	02	01	H5407_016_0	5	5	4	3	Tier 5 - Brands	000010	1	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	016	0	1	02	01	H5407_016_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	016	0	1	02	01	H5407_016_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	016	0	1	02	01	H5407_016_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	016	0	1	02	01	H5407_016_0	5	1	4	3	Tier 1 - Preferred Generics	001000	1	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	021	0	1	02	01	H5407_021_0	5	1	4	1	Tier 1 - Preferred Generics	001000	3	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	021	0	1	02	01	H5407_021_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	021	0	1	02	01	H5407_021_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	021	0	1	02	01	H5407_021_0	5	5	4	3	Tier 5 - Brands	000010	3	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	021	0	1	02	01	H5407_021_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5407	021	0	1	02	01	H5407_021_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	021	0	1	02	01	H5407_021_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	021	0	1	02	01	H5407_021_0	5	1	4	3	Tier 1 - Preferred Generics	001000	3	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	021	0	1	02	01	H5407_021_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	021	0	1	02	01	H5407_021_0	5	5	4	1	Tier 5 - Brands	000010	3	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	65.00	195.00								65.00			195.00								65.00
H5407	021	0	1	02	01	H5407_021_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	021	0	1	02	01	H5407_021_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	022	0	1	02	01	H5407_022_0	5	1	4	1	Tier 1 - Preferred Generics	001000	3	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	022	0	1	02	01	H5407_022_0	5	6	4	1	Tier 6 - Specialty	100000	1	1				Tier 6 - Specialty	110000000010100000000	30									30		30									31	Tier 6 - Specialty	2	1	Tier 6 - Specialty	33									33		33									33	Tier 6 - Specialty																					
H5407	022	0	1	02	01	H5407_022_0	5	1	4	3	Tier 1 - Preferred Generics	001000	3	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
H5407	022	0	1	02	01	H5407_022_0	5	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
H5407	022	0	1	02	01	H5407_022_0	5	3	4	3	Tier 3 - Plus Brands	000001	1	2	1		1	Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	022	0	1	02	01	H5407_022_0	5	6	4	3	Tier 6 - Specialty	100000	1	1	2			Tier 6 - Specialty																							Tier 6 - Specialty			Tier 6 - Specialty																						Tier 6 - Specialty																					
H5407	022	0	1	02	01	H5407_022_0	5	5	4	3	Tier 5 - Brands	000010	3	2	2			Tier 5 - Brands																							Tier 5 - Brands			Tier 5 - Brands																						Tier 5 - Brands																					
H5407	022	0	1	02	01	H5407_022_0	5	5	4	1	Tier 5 - Brands	000010	3	2				Tier 5 - Brands	111000000010010000000	30	90								30										90	31	Tier 5 - Brands	2	2	Tier 5 - Brands																						Tier 5 - Brands	65.00	195.00								65.00			195.00								65.00
H5407	022	0	1	02	01	H5407_022_0	5	4	4	1	Tier 4 - Preferred Brands	000001	1	2				Tier 4 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Preferred Brands	2	2	Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
H5407	022	0	1	02	01	H5407_022_0	5	3	4	1	Tier 3 - Plus Brands	000001	1	2				Tier 3 - Plus Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Plus Brands	2	2	Tier 3 - Plus Brands																						Tier 3 - Plus Brands	10.00	30.00								10.00			30.00								10.00
H5407	022	0	1	02	01	H5407_022_0	5	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
H5407	022	0	1	02	01	H5407_022_0	5	4	4	3	Tier 4 - Preferred Brands	000001	1	2	2			Tier 4 - Preferred Brands																							Tier 4 - Preferred Brands			Tier 4 - Preferred Brands																						Tier 4 - Preferred Brands																					
H5410	001	0	1	01	01	H5410_001_0	6	3	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5410	001	0	1	01	01	H5410_001_0	6	2	4	3	Brand Name Drugs	000010	1	2	2			Brand Name Drugs																							Brand Name Drugs			Brand Name Drugs																						Brand Name Drugs																					
H5410	001	0	1	01	01	H5410_001_0	6	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	100010010010000000000				30			30			30											31	Generic Drugs	1	2	Generic Drugs																						Generic Drugs				0.00			5.00			5.00											5.00
H5410	001	0	1	01	01	H5410_001_0	6	3	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	100010010010000000000				30			30			30											31	Specialty Drugs	2	1	Specialty Drugs				33			33			33											33	Specialty Drugs																					
H5410	001	0	1	01	01	H5410_001_0	6	2	4	1	Brand Name Drugs	000010	1	2				Brand Name Drugs	100010010010000000000				30			30			30											31	Brand Name Drugs	1	2	Brand Name Drugs																						Brand Name Drugs				0.00			10.00			10.00											10.00
H5410	001	0	1	01	01	H5410_001_0	6	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	100010010010000000000				30			30			30											31	Generic Drugs	1	2	Generic Drugs																						Generic Drugs				0.00			5.00			5.00											5.00
H5410	003	0	1	01	01	H5410_003_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5410	003	0	1	01	01	H5410_003_0	8	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5410	003	0	1	01	01	H5410_003_0	8	4	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H5410	003	0	1	01	01	H5410_003_0	8	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H5410	003	0	1	01	01	H5410_003_0	8	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H5410	003	0	1	01	01	H5410_003_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5410	003	0	1	01	01	H5410_003_0	8	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H5410	003	0	1	01	01	H5410_003_0	8	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5410	003	0	1	01	01	H5410_003_0	8	4	4	3	Non-Preferred Brand	000100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5410	003	0	1	01	01	H5410_003_0	8	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5410	005	0	1	01	01	H5410_005_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5410	005	0	1	01	01	H5410_005_0	6	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H5410	005	0	1	01	01	H5410_005_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H5410	005	0	1	01	01	H5410_005_0	6	4	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H5410	005	0	1	01	01	H5410_005_0	6	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5410	005	0	1	01	01	H5410_005_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5410	005	0	1	01	01	H5410_005_0	6	4	4	3	Non-Preferred Brand	000100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5410	005	0	1	01	01	H5410_005_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5410	005	0	1	01	01	H5410_005_0	6	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H5410	005	0	1	01	01	H5410_005_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5414	002	0	1	01	01	H5414_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5414	002	0	1	01	01	H5414_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5414	002	0	1	01	01	H5414_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H5414	002	0	1	01	01	H5414_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5414	002	0	1	01	01	H5414_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	004	0	1	01	01	H5414_004_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5414	004	0	1	01	01	H5414_004_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H5414	004	0	1	01	01	H5414_004_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5414	004	0	1	01	01	H5414_004_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5414	004	0	1	01	01	H5414_004_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	009	0	1	01	01	H5414_009_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5414	009	0	1	01	01	H5414_009_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5414	009	0	1	01	01	H5414_009_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5414	009	0	1	01	01	H5414_009_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5414	009	0	1	01	01	H5414_009_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	010	0	1	01	01	H5414_010_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5414	010	0	1	01	01	H5414_010_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5414	010	0	1	01	01	H5414_010_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5414	010	0	1	01	01	H5414_010_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5414	010	0	1	01	01	H5414_010_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	011	0	1	01	01	H5414_011_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5414	011	0	1	01	01	H5414_011_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5414	011	0	1	01	01	H5414_011_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5414	011	0	1	01	01	H5414_011_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5414	011	0	1	01	01	H5414_011_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5414	011	0	1	01	01	H5414_011_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5414	011	0	1	01	01	H5414_011_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5414	011	0	1	01	01	H5414_011_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5414	011	0	1	01	01	H5414_011_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5414	011	0	1	01	01	H5414_011_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5414	012	0	1	01	01	H5414_012_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5414	012	0	1	01	01	H5414_012_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5414	012	0	1	01	01	H5414_012_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H5414	012	0	1	01	01	H5414_012_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5414	012	0	1	01	01	H5414_012_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	014	0	1	01	01	H5414_014_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5414	014	0	1	01	01	H5414_014_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5414	014	0	1	01	01	H5414_014_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5414	014	0	1	01	01	H5414_014_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5414	014	0	1	01	01	H5414_014_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	015	0	1	01	01	H5414_015_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5414	015	0	1	01	01	H5414_015_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5414	015	0	1	01	01	H5414_015_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H5414	015	0	1	01	01	H5414_015_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5414	015	0	1	01	01	H5414_015_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5414	016	0	1	01	01	H5414_016_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5414	016	0	1	01	01	H5414_016_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5414	016	0	1	01	01	H5414_016_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5414	016	0	1	01	01	H5414_016_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5414	016	0	1	01	01	H5414_016_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5414	016	0	1	01	01	H5414_016_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5414	016	0	1	01	01	H5414_016_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5414	016	0	1	01	01	H5414_016_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5414	016	0	1	01	01	H5414_016_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5414	016	0	1	01	01	H5414_016_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5415	039	0	1	04	01	H5415_039_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5415	039	0	1	04	01	H5415_039_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5415	039	0	1	04	01	H5415_039_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5415	039	0	1	04	01	H5415_039_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5415	039	0	1	04	01	H5415_039_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H5415	039	0	1	04	01	H5415_039_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5415	039	0	1	04	01	H5415_039_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5415	039	0	1	04	01	H5415_039_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5416	001	0	1	01	01	H5416_001_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5416	001	0	1	01	01	H5416_001_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5416	001	0	1	01	01	H5416_001_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5416	001	0	1	01	01	H5416_001_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5416	001	0	1	01	01	H5416_001_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5416	001	0	1	01	01	H5416_001_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5416	001	0	1	01	01	H5416_001_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H5416	001	0	1	01	01	H5416_001_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5416	002	0	1	01	01	H5416_002_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5416	002	0	1	01	01	H5416_002_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5416	002	0	1	01	01	H5416_002_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	002	0	1	01	01	H5416_002_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5416	002	0	1	01	01	H5416_002_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5416	002	0	1	01	01	H5416_002_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5416	002	0	1	01	01	H5416_002_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	002	0	1	01	01	H5416_002_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5416	004	0	1	01	01	H5416_004_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	004	0	1	01	01	H5416_004_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5416	004	0	1	01	01	H5416_004_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5416	004	0	1	01	01	H5416_004_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5416	004	0	1	01	01	H5416_004_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5416	004	0	1	01	01	H5416_004_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	004	0	1	01	01	H5416_004_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5416	004	0	1	01	01	H5416_004_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5416	009	0	1	01	01	H5416_009_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	009	0	1	01	01	H5416_009_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5416	009	0	1	01	01	H5416_009_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5416	009	0	1	01	01	H5416_009_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	009	0	1	01	01	H5416_009_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5416	009	0	1	01	01	H5416_009_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5416	009	0	1	01	01	H5416_009_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5416	009	0	1	01	01	H5416_009_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5416	010	0	1	02	01	H5416_010_0	11	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5416	010	0	1	02	01	H5416_010_0	11	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5416	010	0	1	02	01	H5416_010_0	11	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	010	0	1	02	01	H5416_010_0	11	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5416	010	0	1	02	01	H5416_010_0	11	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5416	010	0	1	02	01	H5416_010_0	11	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5416	010	0	1	02	01	H5416_010_0	11	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5416	010	0	1	02	01	H5416_010_0	11	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5417	001	0	1	04	01	H5417_001_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H5417	001	0	1	04	01	H5417_001_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5417	001	0	1	04	01	H5417_001_0	3	3	3	1	Non Preferred	100100		2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H5417	001	0	1	04	01	H5417_001_0	3	4	3	1	Specialty	010010		1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5417	005	0	1	04	01	H5417_005_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5417	005	0	1	04	01	H5417_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H5417	005	0	1	04	01	H5417_005_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H5417	005	0	1	04	01	H5417_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5417	006	0	1	04	01	H5417_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5417	006	0	1	04	01	H5417_006_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5417	006	0	1	04	01	H5417_006_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5417	006	0	1	04	01	H5417_006_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5419	004	0	1	09	04	H5419_004_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5419	004	0	1	09	04	H5419_004_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5419	004	0	1	09	04	H5419_004_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5419	004	0	1	09	04	H5419_004_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5419	004	0	1	09	04	H5419_004_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5419	004	0	1	09	04	H5419_004_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5419	004	0	1	09	04	H5419_004_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5419	004	0	1	09	04	H5419_004_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5419	004	0	1	09	04	H5419_004_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5419	004	0	1	09	04	H5419_004_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5420	001	0	1	05	01	H5420_001_0	6	1	4	1	Generic	010000	3	2				Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	001	0	1	05	01	H5420_001_0	6	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5420	001	0	1	05	01	H5420_001_0	6	4	4	3	Non-Preferred Brand	000010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5420	001	0	1	05	01	H5420_001_0	6	3	4	3	Formulary Brand	000010	3	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H5420	001	0	1	05	01	H5420_001_0	6	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	001	0	1	05	01	H5420_001_0	6	1	4	3	Generic	010000	3	2	1		1	Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	001	0	1	05	01	H5420_001_0	6	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
H5420	001	0	1	05	01	H5420_001_0	6	4	4	1	Non-Preferred Brand	000010	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00
H5420	001	0	1	05	01	H5420_001_0	6	3	4	1	Formulary Brand	000010	3	2				Formulary Brand	100010010010000000000				30			30			30											31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00
H5420	001	0	1	05	01	H5420_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	003	0	1	05	01	H5420_003_0	6	1	4	1	Generic	010000	3	2				Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	003	0	1	05	01	H5420_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	003	0	1	05	01	H5420_003_0	6	3	4	1	Formulary Brand	000010	3	2				Formulary Brand	100010010010000000000				30			30			30											31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00
H5420	003	0	1	05	01	H5420_003_0	6	4	4	1	Non-Preferred Brand	000010	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00
H5420	003	0	1	05	01	H5420_003_0	6	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5420	003	0	1	05	01	H5420_003_0	6	1	4	3	Generic	010000	3	2	1		1	Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	003	0	1	05	01	H5420_003_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5420	003	0	1	05	01	H5420_003_0	6	3	4	3	Formulary Brand	000010	3	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H5420	003	0	1	05	01	H5420_003_0	6	4	4	3	Non-Preferred Brand	000010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5420	003	0	1	05	01	H5420_003_0	6	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
H5420	004	0	1	05	01	H5420_004_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5420	004	0	1	05	01	H5420_004_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5420	004	0	1	05	01	H5420_004_0	5	3	4	3	Formulary Brand	000010	3	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H5420	004	0	1	05	01	H5420_004_0	5	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	004	0	1	05	01	H5420_004_0	5	1	4	3	Generic	010000	3	2	1		1	Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	004	0	1	05	01	H5420_004_0	5	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
H5420	004	0	1	05	01	H5420_004_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00
H5420	004	0	1	05	01	H5420_004_0	5	3	4	1	Formulary Brand	000010	3	2				Formulary Brand	100010010010000000000				30			30			30											31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00
H5420	004	0	1	05	01	H5420_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	004	0	1	05	01	H5420_004_0	5	1	4	1	Generic	010000	3	2				Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	005	0	1	05	01	H5420_005_0	5	1	4	1	Generic	010000	3	2				Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	005	0	1	05	01	H5420_005_0	5	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
H5420	005	0	1	05	01	H5420_005_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00
H5420	005	0	1	05	01	H5420_005_0	5	3	4	1	Formulary Brand	000010	3	2				Formulary Brand	100010010010000000000				30			30			30											31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00
H5420	005	0	1	05	01	H5420_005_0	5	1	4	3	Generic	010000	3	2	1		1	Generic	100010010010000000000				30			30			30											31	Generic	2	2	Generic																						Generic				0.00			0.00			0.00											0.00
H5420	005	0	1	05	01	H5420_005_0	5	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5420	005	0	1	05	01	H5420_005_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5420	005	0	1	05	01	H5420_005_0	5	3	4	3	Formulary Brand	000010	3	2	2			Formulary Brand																							Formulary Brand			Formulary Brand																						Formulary Brand																					
H5420	005	0	1	05	01	H5420_005_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5420	005	0	1	05	01	H5420_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00
H5420	006	0	1	05	01	H5420_006_0	5	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5420	006	0	1	05	01	H5420_006_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5420	006	0	1	05	01	H5420_006_0	5	2	4	1	Brand	000010	1	2				Brand	110000000010000000000	30									30											31	Brand	2	1	Brand	35									35											35	Brand																					
H5420	006	0	1	05	01	H5420_006_0	5	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5420	006	0	1	05	01	H5420_006_0	5	1	4	3	Generic	010001	3	2	1		1	Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H5420	006	0	1	05	01	H5420_006_0	5	1	4	1	Generic	010001	3	2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H5420	009	0	1	05	01	H5420_009_0	5	3	4	1	Formulary Brand	000010	3	2				Formulary Brand	110000000010000000000	30									30											31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	10.00									10.00											10.00
H5420	009	0	1	05	01	H5420_009_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	110000000010000000000	30									30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00									0.00											0.00
H5420	009	0	1	05	01	H5420_009_0	5	1	4	1	Generic	010000	3	2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	0.00									0.00											0.00
H5420	009	0	1	05	01	H5420_009_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	110000000010000000000	30									30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	25.00									25.00											25.00
H5420	009	0	1	05	01	H5420_009_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5421	064	0	1	09	04	H5421_064_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	064	0	1	09	04	H5421_064_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	064	0	1	09	04	H5421_064_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	064	0	1	09	04	H5421_064_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	064	0	1	09	04	H5421_064_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	064	0	1	09	04	H5421_064_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	064	0	1	09	04	H5421_064_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	064	0	1	09	04	H5421_064_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	065	0	1	09	04	H5421_065_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	065	0	1	09	04	H5421_065_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	065	0	1	09	04	H5421_065_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	065	0	1	09	04	H5421_065_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	065	0	1	09	04	H5421_065_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	065	0	1	09	04	H5421_065_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	065	0	1	09	04	H5421_065_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	065	0	1	09	04	H5421_065_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	066	0	1	09	04	H5421_066_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	066	0	1	09	04	H5421_066_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	066	0	1	09	04	H5421_066_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	066	0	1	09	04	H5421_066_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	066	0	1	09	04	H5421_066_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	066	0	1	09	04	H5421_066_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	066	0	1	09	04	H5421_066_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	066	0	1	09	04	H5421_066_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	067	0	1	09	04	H5421_067_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	067	0	1	09	04	H5421_067_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	067	0	1	09	04	H5421_067_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	067	0	1	09	04	H5421_067_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	067	0	1	09	04	H5421_067_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	067	0	1	09	04	H5421_067_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	067	0	1	09	04	H5421_067_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	067	0	1	09	04	H5421_067_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	068	0	1	09	04	H5421_068_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	068	0	1	09	04	H5421_068_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	068	0	1	09	04	H5421_068_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	068	0	1	09	04	H5421_068_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	068	0	1	09	04	H5421_068_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	068	0	1	09	04	H5421_068_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	068	0	1	09	04	H5421_068_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	068	0	1	09	04	H5421_068_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	069	0	1	09	04	H5421_069_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	069	0	1	09	04	H5421_069_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	069	0	1	09	04	H5421_069_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	069	0	1	09	04	H5421_069_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	069	0	1	09	04	H5421_069_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	069	0	1	09	04	H5421_069_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	069	0	1	09	04	H5421_069_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	069	0	1	09	04	H5421_069_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	070	0	1	09	04	H5421_070_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	070	0	1	09	04	H5421_070_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	070	0	1	09	04	H5421_070_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	070	0	1	09	04	H5421_070_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	071	0	1	09	04	H5421_071_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	071	0	1	09	04	H5421_071_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	071	0	1	09	04	H5421_071_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	071	0	1	09	04	H5421_071_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	072	0	1	09	04	H5421_072_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	072	0	1	09	04	H5421_072_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	072	0	1	09	04	H5421_072_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	072	0	1	09	04	H5421_072_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	073	0	1	09	04	H5421_073_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	073	0	1	09	04	H5421_073_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	073	0	1	09	04	H5421_073_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	073	0	1	09	04	H5421_073_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	074	0	1	09	04	H5421_074_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	074	0	1	09	04	H5421_074_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	074	0	1	09	04	H5421_074_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	074	0	1	09	04	H5421_074_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	075	0	1	09	04	H5421_075_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	075	0	1	09	04	H5421_075_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	075	0	1	09	04	H5421_075_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	075	0	1	09	04	H5421_075_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	103	0	1	09	04	H5421_103_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	103	0	1	09	04	H5421_103_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	103	0	1	09	04	H5421_103_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	103	0	1	09	04	H5421_103_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	103	0	1	09	04	H5421_103_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	103	0	1	09	04	H5421_103_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	103	0	1	09	04	H5421_103_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	103	0	1	09	04	H5421_103_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	104	0	1	09	04	H5421_104_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	104	0	1	09	04	H5421_104_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	104	0	1	09	04	H5421_104_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	104	0	1	09	04	H5421_104_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	109	0	1	09	04	H5421_109_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	109	0	1	09	04	H5421_109_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	109	0	1	09	04	H5421_109_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	109	0	1	09	04	H5421_109_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	109	0	1	09	04	H5421_109_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	109	0	1	09	04	H5421_109_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	109	0	1	09	04	H5421_109_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	109	0	1	09	04	H5421_109_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	110	0	1	09	04	H5421_110_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	110	0	1	09	04	H5421_110_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	110	0	1	09	04	H5421_110_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	110	0	1	09	04	H5421_110_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	115	0	1	09	04	H5421_115_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	115	0	1	09	04	H5421_115_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	115	0	1	09	04	H5421_115_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	115	0	1	09	04	H5421_115_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	115	0	1	09	04	H5421_115_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	115	0	1	09	04	H5421_115_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	115	0	1	09	04	H5421_115_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	115	0	1	09	04	H5421_115_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	116	0	1	09	04	H5421_116_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	116	0	1	09	04	H5421_116_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	116	0	1	09	04	H5421_116_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	116	0	1	09	04	H5421_116_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	127	0	1	09	04	H5421_127_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	127	0	1	09	04	H5421_127_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	127	0	1	09	04	H5421_127_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	127	0	1	09	04	H5421_127_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	127	0	1	09	04	H5421_127_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	127	0	1	09	04	H5421_127_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	127	0	1	09	04	H5421_127_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	127	0	1	09	04	H5421_127_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	128	0	1	09	04	H5421_128_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	128	0	1	09	04	H5421_128_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	128	0	1	09	04	H5421_128_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	128	0	1	09	04	H5421_128_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	133	0	1	09	04	H5421_133_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5421	133	0	1	09	04	H5421_133_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5421	133	0	1	09	04	H5421_133_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5421	133	0	1	09	04	H5421_133_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	133	0	1	09	04	H5421_133_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	133	0	1	09	04	H5421_133_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	133	0	1	09	04	H5421_133_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	133	0	1	09	04	H5421_133_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5421	134	0	1	09	04	H5421_134_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5421	134	0	1	09	04	H5421_134_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H5421	134	0	1	09	04	H5421_134_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5421	134	0	1	09	04	H5421_134_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H5422	002	0	1	01	01	H5422_002_0	10	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5422	002	0	1	01	01	H5422_002_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5422	002	0	1	01	01	H5422_002_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5422	002	0	1	01	01	H5422_002_0	10	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5422	002	0	1	01	01	H5422_002_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5422	002	0	1	01	01	H5422_002_0	10	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5422	002	0	1	01	01	H5422_002_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5422	002	0	1	01	01	H5422_002_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5422	002	0	1	01	01	H5422_002_0	10	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5422	002	0	1	01	01	H5422_002_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5422	006	0	1	01	01	H5422_006_0	10	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5422	006	0	1	01	01	H5422_006_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5422	006	0	1	01	01	H5422_006_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5422	006	0	1	01	01	H5422_006_0	10	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5422	006	0	1	01	01	H5422_006_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5422	006	0	1	01	01	H5422_006_0	10	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5422	006	0	1	01	01	H5422_006_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5422	006	0	1	01	01	H5422_006_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5422	006	0	1	01	01	H5422_006_0	10	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5422	006	0	1	01	01	H5422_006_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5424	001	0	1	04	01	H5424_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5424	001	0	1	04	01	H5424_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5424	001	0	1	04	01	H5424_001_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5424	001	0	1	04	01	H5424_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5425	001	0	1	01	01	H5425_001_0	8	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	001	0	1	01	01	H5425_001_0	8	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	001	0	1	01	01	H5425_001_0	8	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	001	0	1	01	01	H5425_001_0	8	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	001	0	1	01	01	H5425_001_0	8	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	001	0	1	01	01	H5425_001_0	8	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	001	0	1	01	01	H5425_001_0	8	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	001	0	1	01	01	H5425_001_0	8	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	001	0	1	01	01	H5425_001_0	8	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	001	0	1	01	01	H5425_001_0	8	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	003	0	1	01	01	H5425_003_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	003	0	1	01	01	H5425_003_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	003	0	1	01	01	H5425_003_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	003	0	1	01	01	H5425_003_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	003	0	1	01	01	H5425_003_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	003	0	1	01	01	H5425_003_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	003	0	1	01	01	H5425_003_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	003	0	1	01	01	H5425_003_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	003	0	1	01	01	H5425_003_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	003	0	1	01	01	H5425_003_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	004	0	1	01	01	H5425_004_0	11	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	004	0	1	01	01	H5425_004_0	11	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	004	0	1	01	01	H5425_004_0	11	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	004	0	1	01	01	H5425_004_0	11	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	004	0	1	01	01	H5425_004_0	11	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	004	0	1	01	01	H5425_004_0	11	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H5425	004	0	1	01	01	H5425_004_0	11	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	004	0	1	01	01	H5425_004_0	11	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	004	0	1	01	01	H5425_004_0	11	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	004	0	1	01	01	H5425_004_0	11	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	005	0	1	01	01	H5425_005_0	11	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	005	0	1	01	01	H5425_005_0	11	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	005	0	1	01	01	H5425_005_0	11	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	005	0	1	01	01	H5425_005_0	11	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	005	0	1	01	01	H5425_005_0	11	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	005	0	1	01	01	H5425_005_0	11	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			14.00								7.00
H5425	005	0	1	01	01	H5425_005_0	11	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	005	0	1	01	01	H5425_005_0	11	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			14.00								7.00
H5425	005	0	1	01	01	H5425_005_0	11	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	005	0	1	01	01	H5425_005_0	11	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H5425	006	0	1	01	01	H5425_006_0	8	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	006	0	1	01	01	H5425_006_0	8	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	006	0	1	01	01	H5425_006_0	8	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	006	0	1	01	01	H5425_006_0	8	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	006	0	1	01	01	H5425_006_0	8	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	006	0	1	01	01	H5425_006_0	8	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	006	0	1	01	01	H5425_006_0	8	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	006	0	1	01	01	H5425_006_0	8	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H5425	006	0	1	01	01	H5425_006_0	8	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	006	0	1	01	01	H5425_006_0	8	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	007	0	1	01	01	H5425_007_0	9	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	007	0	1	01	01	H5425_007_0	9	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	007	0	1	01	01	H5425_007_0	9	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	007	0	1	01	01	H5425_007_0	9	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	007	0	1	01	01	H5425_007_0	9	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	007	0	1	01	01	H5425_007_0	9	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	007	0	1	01	01	H5425_007_0	9	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	007	0	1	01	01	H5425_007_0	9	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	007	0	1	01	01	H5425_007_0	9	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H5425	007	0	1	01	01	H5425_007_0	9	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H5425	008	0	1	01	01	H5425_008_0	8	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	008	0	1	01	01	H5425_008_0	8	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	008	0	1	01	01	H5425_008_0	8	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	008	0	1	01	01	H5425_008_0	8	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	008	0	1	01	01	H5425_008_0	8	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	008	0	1	01	01	H5425_008_0	8	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	008	0	1	01	01	H5425_008_0	8	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	008	0	1	01	01	H5425_008_0	8	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	008	0	1	01	01	H5425_008_0	8	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	008	0	1	01	01	H5425_008_0	8	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	009	0	1	01	01	H5425_009_0	9	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	009	0	1	01	01	H5425_009_0	9	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	009	0	1	01	01	H5425_009_0	9	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	009	0	1	01	01	H5425_009_0	9	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	009	0	1	01	01	H5425_009_0	9	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	009	0	1	01	01	H5425_009_0	9	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5425	009	0	1	01	01	H5425_009_0	9	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H5425	009	0	1	01	01	H5425_009_0	9	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	009	0	1	01	01	H5425_009_0	9	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	009	0	1	01	01	H5425_009_0	9	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	010	0	1	01	01	H5425_010_0	9	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	010	0	1	01	01	H5425_010_0	9	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5425	010	0	1	01	01	H5425_010_0	9	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H5425	010	0	1	01	01	H5425_010_0	9	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H5425	010	0	1	01	01	H5425_010_0	9	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H5425	011	0	1	01	01	H5425_011_0	9	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	011	0	1	01	01	H5425_011_0	9	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5425	011	0	1	01	01	H5425_011_0	9	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H5425	011	0	1	01	01	H5425_011_0	9	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H5425	011	0	1	01	01	H5425_011_0	9	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H5425	012	0	1	01	01	H5425_012_0	9	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5425	012	0	1	01	01	H5425_012_0	9	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	012	0	1	01	01	H5425_012_0	9	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H5425	012	0	1	01	01	H5425_012_0	9	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H5425	012	0	1	01	01	H5425_012_0	9	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H5425	013	0	1	01	01	H5425_013_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	013	0	1	01	01	H5425_013_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	013	0	1	01	01	H5425_013_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	013	0	1	01	01	H5425_013_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			120.00								60.00
H5425	013	0	1	01	01	H5425_013_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	013	0	1	01	01	H5425_013_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	013	0	1	01	01	H5425_013_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	013	0	1	01	01	H5425_013_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	013	0	1	01	01	H5425_013_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	013	0	1	01	01	H5425_013_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5425	014	0	1	01	01	H5425_014_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	014	0	1	01	01	H5425_014_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	014	0	1	01	01	H5425_014_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	014	0	1	01	01	H5425_014_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	014	0	1	01	01	H5425_014_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	014	0	1	01	01	H5425_014_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	014	0	1	01	01	H5425_014_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	014	0	1	01	01	H5425_014_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	014	0	1	01	01	H5425_014_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5425	014	0	1	01	01	H5425_014_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			120.00								60.00
H5425	015	0	1	01	01	H5425_015_0	11	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	015	0	1	01	01	H5425_015_0	11	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	015	0	1	01	01	H5425_015_0	11	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	015	0	1	01	01	H5425_015_0	11	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	015	0	1	01	01	H5425_015_0	11	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	015	0	1	01	01	H5425_015_0	11	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	015	0	1	01	01	H5425_015_0	11	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	015	0	1	01	01	H5425_015_0	11	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5425	015	0	1	01	01	H5425_015_0	11	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			120.00								60.00
H5425	015	0	1	01	01	H5425_015_0	11	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	016	0	1	01	01	H5425_016_0	11	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5425	016	0	1	01	01	H5425_016_0	11	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5425	016	0	1	01	01	H5425_016_0	11	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			120.00								60.00
H5425	016	0	1	01	01	H5425_016_0	11	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5425	016	0	1	01	01	H5425_016_0	11	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5425	016	0	1	01	01	H5425_016_0	11	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	016	0	1	01	01	H5425_016_0	11	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H5425	016	0	1	01	01	H5425_016_0	11	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H5425	016	0	1	01	01	H5425_016_0	11	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H5425	016	0	1	01	01	H5425_016_0	11	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H5426	001	0	1	02	01	H5426_001_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	001	0	1	02	01	H5426_001_0	8	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	001	0	1	02	01	H5426_001_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	001	0	1	02	01	H5426_001_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5426	001	0	1	02	01	H5426_001_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5426	001	0	1	02	01	H5426_001_0	8	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5426	001	0	1	02	01	H5426_001_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	001	0	1	02	01	H5426_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	002	0	1	02	01	H5426_002_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	002	0	1	02	01	H5426_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	002	0	1	02	01	H5426_002_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	002	0	1	02	01	H5426_002_0	8	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	002	0	1	02	01	H5426_002_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	002	0	1	02	01	H5426_002_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5426	002	0	1	02	01	H5426_002_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5426	002	0	1	02	01	H5426_002_0	8	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5426	007	0	1	02	01	H5426_007_0	9	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	007	0	1	02	01	H5426_007_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	007	0	1	02	01	H5426_007_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	007	0	1	02	01	H5426_007_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	008	0	1	02	01	H5426_008_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	008	0	1	02	01	H5426_008_0	9	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	008	0	1	02	01	H5426_008_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	008	0	1	02	01	H5426_008_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	013	0	1	01	01	H5426_013_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	013	0	1	01	01	H5426_013_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	013	0	1	01	01	H5426_013_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	013	0	1	01	01	H5426_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	014	0	1	01	01	H5426_014_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	014	0	1	01	01	H5426_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	014	0	1	01	01	H5426_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	014	0	1	01	01	H5426_014_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5426	015	0	1	01	01	H5426_015_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5426	015	0	1	01	01	H5426_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
H5426	015	0	1	01	01	H5426_015_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00
H5426	015	0	1	01	01	H5426_015_0	6	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5427	053	0	1	02	01	H5427_053_0	11	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	053	0	1	02	01	H5427_053_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	053	0	1	02	01	H5427_053_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	053	0	1	02	01	H5427_053_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	054	0	1	02	01	H5427_054_0	11	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			100.00								50.00
H5427	054	0	1	02	01	H5427_054_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	054	0	1	02	01	H5427_054_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00
H5427	054	0	1	02	01	H5427_054_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	056	0	1	02	01	H5427_056_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	056	0	1	02	01	H5427_056_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00
H5427	056	0	1	02	01	H5427_056_0	11	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			100.00								50.00
H5427	056	0	1	02	01	H5427_056_0	11	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	056	0	1	02	01	H5427_056_0	11	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5427	056	0	1	02	01	H5427_056_0	11	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5427	056	0	1	02	01	H5427_056_0	11	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5427	056	0	1	02	01	H5427_056_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	059	0	1	02	01	H5427_059_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	059	0	1	02	01	H5427_059_0	9	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	059	0	1	02	01	H5427_059_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	059	0	1	02	01	H5427_059_0	9	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	060	0	1	02	01	H5427_060_0	9	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5427	060	0	1	02	01	H5427_060_0	9	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5427	060	0	1	02	01	H5427_060_0	9	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5427	060	0	1	02	01	H5427_060_0	9	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	060	0	1	02	01	H5427_060_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	060	0	1	02	01	H5427_060_0	9	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	060	0	1	02	01	H5427_060_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	060	0	1	02	01	H5427_060_0	9	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	062	0	1	02	01	H5427_062_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	062	0	1	02	01	H5427_062_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	062	0	1	02	01	H5427_062_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	062	0	1	02	01	H5427_062_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5427	062	0	1	02	01	H5427_062_0	8	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5427	062	0	1	02	01	H5427_062_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5427	062	0	1	02	01	H5427_062_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	062	0	1	02	01	H5427_062_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	070	0	1	01	01	H5427_070_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	070	0	1	01	01	H5427_070_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	070	0	1	01	01	H5427_070_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	070	0	1	01	01	H5427_070_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	070	0	1	01	01	H5427_070_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	070	0	1	01	01	H5427_070_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5427	070	0	1	01	01	H5427_070_0	8	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5427	070	0	1	01	01	H5427_070_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5427	072	0	1	01	01	H5427_072_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5427	072	0	1	01	01	H5427_072_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00								20.00			40.00								20.00
H5427	072	0	1	01	01	H5427_072_0	11	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			120.00								60.00
H5427	072	0	1	01	01	H5427_072_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	075	0	1	02	01	H5427_075_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5427	075	0	1	02	01	H5427_075_0	11	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			170.00								85.00
H5427	075	0	1	02	01	H5427_075_0	11	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	120.00								40.00			80.00								40.00
H5427	075	0	1	02	01	H5427_075_0	11	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5428	001	0	1	01	01	H5428_001_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010000000000	31	93								31											31	Brand	2	2	Brand																						Brand	41.50	124.50								41.50											41.50
H5428	001	0	1	01	01	H5428_001_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	93								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5429	001	0	1	04	01	H5429_001_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5429	001	0	1	04	01	H5429_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5429	001	0	1	04	01	H5429_001_0	11	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5429	001	0	1	04	01	H5429_001_0	11	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5429	005	0	1	04	01	H5429_005_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5429	005	0	1	04	01	H5429_005_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5429	005	0	1	04	01	H5429_005_0	10	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5429	005	0	1	04	01	H5429_005_0	10	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5429	015	0	1	04	01	H5429_015_0	10	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5429	015	0	1	04	01	H5429_015_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5429	015	0	1	04	01	H5429_015_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5429	015	0	1	04	01	H5429_015_0	10	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5429	020	0	1	04	01	H5429_020_0	11	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5429	020	0	1	04	01	H5429_020_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00	30.00							15.00			45.00								15.00
H5429	020	0	1	04	01	H5429_020_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00	100.00							50.00			150.00								50.00
H5429	020	0	1	04	01	H5429_020_0	11	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5431	001	0	1	01	01	H5431_001_0	7	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5431	001	0	1	01	01	H5431_001_0	7	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5431	001	0	1	01	01	H5431_001_0	7	3	4	3	Preferred Brand	000010	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5431	001	0	1	01	01	H5431_001_0	7	2	4	3	Non-Preferred Generic	000100	3	2	1		1	Non-Preferred Generic	100010010010000000000				30			30			30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											0.00
H5431	001	0	1	01	01	H5431_001_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	100010010010000000000				30			30			30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00
H5431	001	0	1	01	01	H5431_001_0	7	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H5431	001	0	1	01	01	H5431_001_0	7	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				40.00			40.00			40.00											40.00
H5431	001	0	1	01	01	H5431_001_0	7	3	4	1	Preferred Brand	000010	3	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			10.00			10.00											10.00
H5431	001	0	1	01	01	H5431_001_0	7	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	100010010010000000000				30			30			30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											0.00
H5431	001	0	1	01	01	H5431_001_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	100010010010000000000				30			30			30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00
H5431	002	0	1	01	01	H5431_002_0	6	3	4	3	Preferred Brand	000010	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5431	002	0	1	01	01	H5431_002_0	6	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5431	002	0	1	01	01	H5431_002_0	6	2	4	3	Non-Preferred Generic	000100	3	2	1		1	Non-Preferred Generic	100010010010000000000				30			30			30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00
H5431	002	0	1	01	01	H5431_002_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	100010010010000000000				30			30			30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00
H5431	002	0	1	01	01	H5431_002_0	6	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				30			30			30											31	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
H5431	002	0	1	01	01	H5431_002_0	6	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	100010010010000000000				30			30			30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				40.00			40.00			40.00											40.00
H5431	002	0	1	01	01	H5431_002_0	6	3	4	1	Preferred Brand	000010	3	2				Preferred Brand	100010010010000000000				30			30			30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				0.00			10.00			10.00											10.00
H5431	002	0	1	01	01	H5431_002_0	6	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	100010010010000000000				30			30			30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00
H5431	002	0	1	01	01	H5431_002_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	100010010010000000000				30			30			30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00
H5431	002	0	1	01	01	H5431_002_0	6	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5431	005	0	1	01	01	H5431_005_0	8	3	4	3	Preferred Brand	000010	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5431	005	0	1	01	01	H5431_005_0	8	3	4	1	Preferred Brand	000010	3	2				Preferred Brand	110000000010000000000	30									30											31	Preferred Brand	2	1	Preferred Brand	33									33											33	Preferred Brand																					
H5431	005	0	1	01	01	H5431_005_0	8	2	4	1	Non-Preferred Generic	000100	3	2				Non-Preferred Generic	110000000010000000000	30									30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	0.00									0.00											0.00
H5431	005	0	1	01	01	H5431_005_0	8	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	110000000010000000000	30									30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00									0.00											0.00
H5431	005	0	1	01	01	H5431_005_0	8	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5431	005	0	1	01	01	H5431_005_0	8	5	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5431	005	0	1	01	01	H5431_005_0	8	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5431	005	0	1	01	01	H5431_005_0	8	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110000000010000000000	30									30											31	Non-Preferred Brand	2	1	Non-Preferred Brand	33									33											33	Non-Preferred Brand																					
H5431	005	0	1	01	01	H5431_005_0	8	2	4	3	Non-Preferred Generic	000100	3	2	1		1	Non-Preferred Generic	110000000010000000000	30									30											31	Non-Preferred Generic	2	2	Non-Preferred Generic																						Non-Preferred Generic	0.00									0.00											0.00
H5431	005	0	1	01	01	H5431_005_0	8	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	110000000010000000000	30									30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00									0.00											0.00
H5433	001	0	1	01	01	H5433_001_0	5	1	4	3	Generics	010000	1	2	1		1	Generics	111000000010000000000	30	90								30											31	Generics	2	2	Generics																						Generics	0.00	0.00								0.00											0.00
H5433	001	0	1	01	01	H5433_001_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5434	001	0	1	04	01	H5434_001_0	7	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5434	001	0	1	04	01	H5434_001_0	7	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	001	0	1	04	01	H5434_001_0	7	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	001	0	1	04	01	H5434_001_0	7	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	002	0	1	04	01	H5434_002_0	5	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5434	002	0	1	04	01	H5434_002_0	5	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	002	0	1	04	01	H5434_002_0	5	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	002	0	1	04	01	H5434_002_0	5	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	014	0	1	04	01	H5434_014_0	6	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	014	0	1	04	01	H5434_014_0	6	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	014	0	1	04	01	H5434_014_0	6	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5434	014	0	1	04	01	H5434_014_0	6	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	015	0	1	04	01	H5434_015_0	5	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5434	015	0	1	04	01	H5434_015_0	5	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	015	0	1	04	01	H5434_015_0	5	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	015	0	1	04	01	H5434_015_0	5	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	016	0	1	04	01	H5434_016_0	5	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	016	0	1	04	01	H5434_016_0	5	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	016	0	1	04	01	H5434_016_0	5	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5434	016	0	1	04	01	H5434_016_0	5	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	018	0	1	04	01	H5434_018_0	5	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5434	018	0	1	04	01	H5434_018_0	5	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
H5434	018	0	1	04	01	H5434_018_0	5	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
H5434	018	0	1	04	01	H5434_018_0	5	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
H5435	013	0	1	09	04	H5435_013_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	013	0	1	09	04	H5435_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5435	013	0	1	09	04	H5435_013_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5435	013	0	1	09	04	H5435_013_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	014	0	1	09	04	H5435_014_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	014	0	1	09	04	H5435_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5435	014	0	1	09	04	H5435_014_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5435	014	0	1	09	04	H5435_014_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	022	0	1	09	04	H5435_022_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	022	0	1	09	04	H5435_022_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	64.00	192.00								64.00						182.00			192.00		64.00
H5435	022	0	1	09	04	H5435_022_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	022	0	1	09	04	H5435_022_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00						92.00			102.00		34.00
H5435	023	0	1	09	04	H5435_023_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5435	023	0	1	09	04	H5435_023_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5435	023	0	1	09	04	H5435_023_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	023	0	1	09	04	H5435_023_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	024	0	1	09	04	H5435_024_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	024	0	1	09	04	H5435_024_0	7	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5435	024	0	1	09	04	H5435_024_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	024	0	1	09	04	H5435_024_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5435	025	0	1	09	04	H5435_025_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	025	0	1	09	04	H5435_025_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00						92.00			102.00		34.00
H5435	025	0	1	09	04	H5435_025_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	64.00	192.00								64.00						182.00			192.00		64.00
H5435	025	0	1	09	04	H5435_025_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	027	0	1	09	04	H5435_027_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	027	0	1	09	04	H5435_027_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	027	0	1	09	04	H5435_027_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00						92.00			102.00		34.00
H5435	027	0	1	09	04	H5435_027_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	64.00	192.00								64.00						182.00			192.00		64.00
H5435	030	0	1	09	04	H5435_030_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5435	030	0	1	09	04	H5435_030_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	64.00	192.00								64.00						182.00			192.00		64.00
H5435	030	0	1	09	04	H5435_030_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5435	030	0	1	09	04	H5435_030_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00						92.00			102.00		34.00
H5436	001	0	1	04	01	H5436_001_0	8	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5436	001	0	1	04	01	H5436_001_0	8	2	4	1	Preferred Brand Name	000001	1	2				Preferred Brand Name	111000000010010000000	30	90								30										90	31	Preferred Brand Name	1	2	Preferred Brand Name																						Preferred Brand Name	25.00	75.00								25.00			75.00								25.00
H5436	001	0	1	04	01	H5436_001_0	8	3	4	1	Non-Preferred Brand Name	100000	1	2				Non-Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non-Preferred Brand Name	1	2	Non-Preferred Brand Name																						Non-Preferred Brand Name	50.00	150.00								50.00			150.00								50.00
H5436	001	0	1	04	01	H5436_001_0	8	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5436	002	0	1	04	01	H5436_002_0	8	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	1	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5436	002	0	1	04	01	H5436_002_0	8	2	4	1	Preferred Brand Name	000001	1	2				Preferred Brand Name	111000000010010000000	30	90								30										90	31	Preferred Brand Name	1	2	Preferred Brand Name																						Preferred Brand Name	25.00	75.00								25.00			75.00								25.00
H5436	002	0	1	04	01	H5436_002_0	8	3	4	1	Non-Preferred Brand Name	100000	1	2				Non-Preferred Brand Name	111000000010010000000	30	90								30										90	31	Non-Preferred Brand Name	1	2	Non-Preferred Brand Name																						Non-Preferred Brand Name	50.00	150.00								50.00			150.00								50.00
H5436	002	0	1	04	01	H5436_002_0	8	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5437	001	0	1	04	01	H5437_001_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5437	001	0	1	04	01	H5437_001_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5437	001	0	1	04	01	H5437_001_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	23.00	69.00									23.00					46.00			69.00		23.00
H5437	001	0	1	04	01	H5437_001_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5437	001	0	1	04	01	H5437_001_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5437	003	0	1	04	01	H5437_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5437	003	0	1	04	01	H5437_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5437	003	0	1	04	01	H5437_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
H5437	003	0	1	04	01	H5437_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
H5437	003	0	1	04	01	H5437_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5437	004	0	1	04	01	H5437_004_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5437	004	0	1	04	01	H5437_004_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5437	004	0	1	04	01	H5437_004_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5437	004	0	1	04	01	H5437_004_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5437	004	0	1	04	01	H5437_004_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5437	004	0	1	04	01	H5437_004_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5437	004	0	1	04	01	H5437_004_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5437	004	0	1	04	01	H5437_004_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5437	004	0	1	04	01	H5437_004_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5437	004	0	1	04	01	H5437_004_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5437	005	0	1	04	01	H5437_005_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5437	005	0	1	04	01	H5437_005_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
H5437	005	0	1	04	01	H5437_005_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
H5437	005	0	1	04	01	H5437_005_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5437	005	0	1	04	01	H5437_005_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5437	006	0	1	04	01	H5437_006_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5437	006	0	1	04	01	H5437_006_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
H5437	006	0	1	04	01	H5437_006_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
H5437	006	0	1	04	01	H5437_006_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5437	006	0	1	04	01	H5437_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5437	007	0	1	04	01	H5437_007_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5437	007	0	1	04	01	H5437_007_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5437	007	0	1	04	01	H5437_007_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5437	007	0	1	04	01	H5437_007_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5437	007	0	1	04	01	H5437_007_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5437	007	0	1	04	01	H5437_007_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5437	007	0	1	04	01	H5437_007_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5437	007	0	1	04	01	H5437_007_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5437	007	0	1	04	01	H5437_007_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5437	007	0	1	04	01	H5437_007_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5439	001	0	1	04	01	H5439_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5439	001	0	1	04	01	H5439_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H5439	001	0	1	04	01	H5439_001_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5439	001	0	1	04	01	H5439_001_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5439	001	0	1	04	01	H5439_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	78.00	234.00	156.00							78.00						195.00	156.00	78.00	234.00	156.00	78.00
H5449	001	0	1	04	01	H5449_001_0	6	1	2	1	Generic	011000		2				Generic	111000000001010000000	31	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		10.00								5.00
H5449	001	0	1	04	01	H5449_001_0	6	4	2	1	Specialty	100011		1				Specialty	110000000001000000000	31										10										31	Specialty	2	1	Specialty	25										25										25	Specialty																					
H5449	001	0	1	04	01	H5449_001_0	6	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	31	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00									70.00		140.00								70.00
H5449	001	0	1	04	01	H5449_001_0	6	2	2	1	Preferred Brand	000011		2				Preferred Brand	111000000001010000000	31	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00									40.00		80.00								40.00
H5470	002	0	1	04	01	H5470_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5470	002	0	1	04	01	H5470_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5470	002	0	1	04	01	H5470_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H5470	002	0	1	04	01	H5470_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5470	002	0	1	04	01	H5470_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5470	002	0	1	04	01	H5470_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H5470	002	0	1	04	01	H5470_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
H5470	002	0	1	04	01	H5470_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5485	001	0	1	09	04	H5485_001_0	11	1	4	1	Generic	011100	1	2				Generic	110100000010001000000	30		60							30			60								31	Generic	2	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00
H5485	001	0	1	09	04	H5485_001_0	11	4	4	1	Specialty	000001	1	1				Specialty	110100000010001000000	30		60							30			30								31	Specialty	2	1	Specialty	25		25							25				25							25	Specialty																					
H5485	001	0	1	09	04	H5485_001_0	11	3	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	110100000010001000000	30		60							30			60								31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00
H5485	001	0	1	09	04	H5485_001_0	11	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	110100000010001000000	30		60							30			60								31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00
H5501	001	0	1	04	01	H5501_001_0	11	1	4	1	Generic	011100	3	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H5501	001	0	1	04	01	H5501_001_0	11	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	100.00		50.00	150.00		50.00			100.00								50.00
H5501	001	0	1	04	01	H5501_001_0	11	4	4	3	Specialty	110010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5501	001	0	1	04	01	H5501_001_0	11	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5501	001	0	1	04	01	H5501_001_0	11	2	4	3	Preferred Brand	000001	3	2	1		1	Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H5501	001	0	1	04	01	H5501_001_0	11	1	4	3	Generic	011100	3	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	0.00		5.00	15.00		5.00			0.00								5.00
H5501	001	0	1	04	01	H5501_001_0	11	4	4	1	Specialty	110010	1	1				Specialty	100011011010010000000				30	90		30	90		30										90	31	Specialty	2	1	Specialty				20	20		20	20		20			20								20	Specialty																					
H5501	001	0	1	04	01	H5501_001_0	11	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand				25.00	50.00		25.00	75.00		25.00			50.00								25.00
H5507	001	0	1	04	01	H5507_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5507	001	0	1	04	01	H5507_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5507	001	0	1	04	01	H5507_001_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5507	001	0	1	04	01	H5507_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5508	001	0	1	04	01	H5508_001_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H5508	001	0	1	04	01	H5508_001_0	4	2	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H5508	001	0	1	04	01	H5508_001_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5508	001	0	1	04	01	H5508_001_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5508	001	0	1	04	01	H5508_001_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5508	001	0	1	04	01	H5508_001_0	4	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H5508	001	0	1	04	01	H5508_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H5508	001	0	1	04	01	H5508_001_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H5508	001	0	1	04	01	H5508_001_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5508	001	0	1	04	01	H5508_001_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H5508	003	0	1	04	01	H5508_003_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H5508	003	0	1	04	01	H5508_003_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H5508	003	0	1	04	01	H5508_003_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5508	003	0	1	04	01	H5508_003_0	4	2	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H5508	003	0	1	04	01	H5508_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H5509	001	0	1	04	01	H5509_001_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	001	0	1	04	01	H5509_001_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	001	0	1	04	01	H5509_001_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	001	0	1	04	01	H5509_001_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	001	0	1	04	01	H5509_001_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	001	0	1	04	01	H5509_001_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	001	0	1	04	01	H5509_001_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	001	0	1	04	01	H5509_001_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	003	0	1	04	01	H5509_003_0	6	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	003	0	1	04	01	H5509_003_0	6	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	003	0	1	04	01	H5509_003_0	6	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	003	0	1	04	01	H5509_003_0	6	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	003	0	1	04	01	H5509_003_0	6	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	003	0	1	04	01	H5509_003_0	6	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	003	0	1	04	01	H5509_003_0	6	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	003	0	1	04	01	H5509_003_0	6	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	004	0	1	04	01	H5509_004_0	7	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	004	0	1	04	01	H5509_004_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	004	0	1	04	01	H5509_004_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	004	0	1	04	01	H5509_004_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	004	0	1	04	01	H5509_004_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	004	0	1	04	01	H5509_004_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	004	0	1	04	01	H5509_004_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	004	0	1	04	01	H5509_004_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	004	0	1	04	01	H5509_004_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	004	0	1	04	01	H5509_004_0	7	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	005	0	1	04	01	H5509_005_0	6	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	005	0	1	04	01	H5509_005_0	6	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	005	0	1	04	01	H5509_005_0	6	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	005	0	1	04	01	H5509_005_0	6	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	005	0	1	04	01	H5509_005_0	6	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	005	0	1	04	01	H5509_005_0	6	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	005	0	1	04	01	H5509_005_0	6	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	005	0	1	04	01	H5509_005_0	6	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	005	0	1	04	01	H5509_005_0	6	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	005	0	1	04	01	H5509_005_0	6	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	006	0	1	04	01	H5509_006_0	8	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	006	0	1	04	01	H5509_006_0	8	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	006	0	1	04	01	H5509_006_0	8	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	006	0	1	04	01	H5509_006_0	8	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	006	0	1	04	01	H5509_006_0	8	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	006	0	1	04	01	H5509_006_0	8	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	006	0	1	04	01	H5509_006_0	8	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	006	0	1	04	01	H5509_006_0	8	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	006	0	1	04	01	H5509_006_0	8	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	006	0	1	04	01	H5509_006_0	8	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	007	0	1	04	01	H5509_007_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	007	0	1	04	01	H5509_007_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	007	0	1	04	01	H5509_007_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	007	0	1	04	01	H5509_007_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	007	0	1	04	01	H5509_007_0	7	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	007	0	1	04	01	H5509_007_0	7	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	007	0	1	04	01	H5509_007_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	007	0	1	04	01	H5509_007_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	007	0	1	04	01	H5509_007_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	007	0	1	04	01	H5509_007_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	008	0	1	04	01	H5509_008_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	008	0	1	04	01	H5509_008_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	008	0	1	04	01	H5509_008_0	7	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	008	0	1	04	01	H5509_008_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	008	0	1	04	01	H5509_008_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	008	0	1	04	01	H5509_008_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	008	0	1	04	01	H5509_008_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	008	0	1	04	01	H5509_008_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	008	0	1	04	01	H5509_008_0	7	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	008	0	1	04	01	H5509_008_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	009	0	1	04	01	H5509_009_0	9	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	009	0	1	04	01	H5509_009_0	9	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	009	0	1	04	01	H5509_009_0	9	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	009	0	1	04	01	H5509_009_0	9	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	009	0	1	04	01	H5509_009_0	9	5	4	3	OTHER - SPECIAL NEEDS	001001	1	2	1		1	OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	009	0	1	04	01	H5509_009_0	9	1	4	3	PREFERRED GENERIC	001000	3	2	2			PREFERRED GENERIC																							PREFERRED GENERIC			PREFERRED GENERIC																						PREFERRED GENERIC																					
H5509	009	0	1	04	01	H5509_009_0	9	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	009	0	1	04	01	H5509_009_0	9	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	009	0	1	04	01	H5509_009_0	9	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	009	0	1	04	01	H5509_009_0	9	5	4	1	OTHER - SPECIAL NEEDS	001001	1	2				OTHER - SPECIAL NEEDS	111000000010010000000	30	90								30										90	31	OTHER - SPECIAL NEEDS	2	2	OTHER - SPECIAL NEEDS																						OTHER - SPECIAL NEEDS	0.00	0.00								0.00			0.00								0.00
H5509	010	0	1	04	01	H5509_010_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	010	0	1	04	01	H5509_010_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	010	0	1	04	01	H5509_010_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	010	0	1	04	01	H5509_010_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	010	0	1	04	01	H5509_010_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	010	0	1	04	01	H5509_010_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	010	0	1	04	01	H5509_010_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	010	0	1	04	01	H5509_010_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	011	0	1	04	01	H5509_011_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	011	0	1	04	01	H5509_011_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	011	0	1	04	01	H5509_011_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	011	0	1	04	01	H5509_011_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	011	0	1	04	01	H5509_011_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	011	0	1	04	01	H5509_011_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	011	0	1	04	01	H5509_011_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	011	0	1	04	01	H5509_011_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	012	0	1	04	01	H5509_012_0	7	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	012	0	1	04	01	H5509_012_0	7	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	012	0	1	04	01	H5509_012_0	7	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	012	0	1	04	01	H5509_012_0	7	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5509	012	0	1	04	01	H5509_012_0	7	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	012	0	1	04	01	H5509_012_0	7	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	012	0	1	04	01	H5509_012_0	7	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	012	0	1	04	01	H5509_012_0	7	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	013	0	1	04	01	H5509_013_0	6	1	4	1	PREFERRED GENERIC	001000	3	2				PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	013	0	1	04	01	H5509_013_0	6	2	4	1	PREFERRED BRAND	000001	1	2				PREFERRED BRAND	111000000010010000000	30	90								30										90	31	PREFERRED BRAND	2	2	PREFERRED BRAND																						PREFERRED BRAND	25.00	50.00								25.00			50.00								25.00
H5509	013	0	1	04	01	H5509_013_0	6	3	4	1	NON-PREFERRED BRAND	100100	1	2				NON-PREFERRED BRAND	111000000010010000000	30	90								30										90	31	NON-PREFERRED BRAND	2	2	NON-PREFERRED BRAND																						NON-PREFERRED BRAND	50.00	150.00								50.00			150.00								50.00
H5509	013	0	1	04	01	H5509_013_0	6	4	4	3	SPECIALTY	010010	1	1	2			SPECIALTY																							SPECIALTY			SPECIALTY																						SPECIALTY																					
H5509	013	0	1	04	01	H5509_013_0	6	1	4	3	PREFERRED GENERIC	001000	3	2	1		1	PREFERRED GENERIC	111000000010010000000	30	90								30										90	31	PREFERRED GENERIC	2	2	PREFERRED GENERIC																						PREFERRED GENERIC	5.00	10.00								5.00			10.00								5.00
H5509	013	0	1	04	01	H5509_013_0	6	2	4	3	PREFERRED BRAND	000001	1	2	2			PREFERRED BRAND																							PREFERRED BRAND			PREFERRED BRAND																						PREFERRED BRAND																					
H5509	013	0	1	04	01	H5509_013_0	6	3	4	3	NON-PREFERRED BRAND	100100	1	2	2			NON-PREFERRED BRAND																							NON-PREFERRED BRAND			NON-PREFERRED BRAND																						NON-PREFERRED BRAND																					
H5509	013	0	1	04	01	H5509_013_0	6	4	4	1	SPECIALTY	010010	1	1				SPECIALTY	110000000010000000000	30									30											31	SPECIALTY	2	1	SPECIALTY	30									30											30	SPECIALTY																					
H5510	002	0	1	04	01	H5510_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5510	002	0	1	04	01	H5510_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5510	002	0	1	04	01	H5510_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5510	002	0	1	04	01	H5510_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5510	002	0	1	04	01	H5510_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5510	002	0	1	04	01	H5510_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5510	002	0	1	04	01	H5510_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5510	002	0	1	04	01	H5510_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5510	002	0	1	04	01	H5510_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5510	002	0	1	04	01	H5510_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5510	003	0	1	04	01	H5510_003_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5510	003	0	1	04	01	H5510_003_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H5510	003	0	1	04	01	H5510_003_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5510	003	0	1	04	01	H5510_003_0	8	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5510	003	0	1	04	01	H5510_003_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5510	005	0	1	04	01	H5510_005_0	8	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5510	005	0	1	04	01	H5510_005_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5510	005	0	1	04	01	H5510_005_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H5510	005	0	1	04	01	H5510_005_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5510	005	0	1	04	01	H5510_005_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5510	006	0	1	04	01	H5510_006_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5510	006	0	1	04	01	H5510_006_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5510	006	0	1	04	01	H5510_006_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5510	006	0	1	04	01	H5510_006_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5510	006	0	1	04	01	H5510_006_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5510	006	0	1	04	01	H5510_006_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5510	006	0	1	04	01	H5510_006_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5510	006	0	1	04	01	H5510_006_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5510	006	0	1	04	01	H5510_006_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5510	006	0	1	04	01	H5510_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5512	001	0	1	04	01	H5512_001_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5512	001	0	1	04	01	H5512_001_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				97.00	242.50		97.00	291.00			97.00					194.00			291.00		97.00
H5512	001	0	1	04	01	H5512_001_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				45.00	112.50		45.00	135.00			45.00					90.00			135.00		45.00
H5512	001	0	1	04	01	H5512_001_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				2.00	5.00		2.00	6.00			2.00					4.00			6.00		2.00
H5512	001	0	1	04	01	H5512_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5512	002	0	1	04	01	H5512_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5512	002	0	1	04	01	H5512_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5512	002	0	1	04	01	H5512_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5512	002	0	1	04	01	H5512_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5512	002	0	1	04	01	H5512_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5512	002	0	1	04	01	H5512_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5512	002	0	1	04	01	H5512_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5512	002	0	1	04	01	H5512_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5512	002	0	1	04	01	H5512_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5512	002	0	1	04	01	H5512_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5512	008	0	1	04	01	H5512_008_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5512	008	0	1	04	01	H5512_008_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5512	008	0	1	04	01	H5512_008_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				24.00	60.00		24.00	72.00			24.00					48.00			72.00		24.00
H5512	008	0	1	04	01	H5512_008_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5512	008	0	1	04	01	H5512_008_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5512	009	0	1	04	01	H5512_009_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5512	009	0	1	04	01	H5512_009_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5512	009	0	1	04	01	H5512_009_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5512	009	0	1	04	01	H5512_009_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5512	009	0	1	04	01	H5512_009_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5512	009	0	1	04	01	H5512_009_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5512	009	0	1	04	01	H5512_009_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5512	009	0	1	04	01	H5512_009_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5512	009	0	1	04	01	H5512_009_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5512	009	0	1	04	01	H5512_009_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5516	001	0	1	04	01	H5516_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5516	001	0	1	04	01	H5516_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5516	001	0	1	04	01	H5516_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5516	001	0	1	04	01	H5516_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5517	002	0	1	04	01	H5517_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5517	002	0	1	04	01	H5517_002_0	6	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H5517	002	0	1	04	01	H5517_002_0	6	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H5517	002	0	1	04	01	H5517_002_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5517	002	0	1	04	01	H5517_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5517	002	0	1	04	01	H5517_002_0	6	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	58.00	174.00								58.00			174.00								58.00
H5517	002	0	1	04	01	H5517_002_0	6	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H5517	002	0	1	04	01	H5517_002_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5517	003	0	1	04	01	H5517_003_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00			174.00								58.00
H5517	003	0	1	04	01	H5517_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	30									30											30	Specialty																					
H5517	003	0	1	04	01	H5517_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5517	003	0	1	04	01	H5517_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5517	004	0	1	04	01	H5517_004_0	7	4	3	1	Specialty	010010		1				Specialty	110000000010000000000	30									30											31	Specialty	2	1	Specialty	33									33											33	Specialty																					
H5517	004	0	1	04	01	H5517_004_0	7	1	3	1	Preferred Generic	001001		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00											5.00
H5517	004	0	1	04	01	H5517_004_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	64.00								32.00											32.00
H5517	004	0	1	04	01	H5517_004_0	7	3	3	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	186.00								62.00											62.00
H5517	005	0	1	04	01	H5517_005_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5517	005	0	1	04	01	H5517_005_0	5	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5517	005	0	1	04	01	H5517_005_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H5517	005	0	1	04	01	H5517_005_0	5	2	4	3	Preferred Brand	001000	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5517	005	0	1	04	01	H5517_005_0	5	2	4	1	Preferred Brand	001000	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5517	005	0	1	04	01	H5517_005_0	5	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00			174.00								58.00
H5517	005	0	1	04	01	H5517_005_0	5	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H5517	005	0	1	04	01	H5517_005_0	5	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H5520	002	0	1	04	01	H5520_002_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5520	002	0	1	04	01	H5520_002_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00						150.00	120.00	60.00	180.00	120.00	60.00
H5520	002	0	1	04	01	H5520_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
H5520	002	0	1	04	01	H5520_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5520	002	0	1	04	01	H5520_002_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	004	0	1	04	01	H5520_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5520	004	0	1	04	01	H5520_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
H5520	004	0	1	04	01	H5520_004_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00						150.00	120.00	60.00	180.00	120.00	60.00
H5520	004	0	1	04	01	H5520_004_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5520	004	0	1	04	01	H5520_004_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	005	0	1	04	01	H5520_005_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	005	0	1	04	01	H5520_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00						12.00	12.00	6.00	18.00	12.00	6.00
H5520	005	0	1	04	01	H5520_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00	80.00							40.00						80.00	80.00	40.00	120.00	80.00	40.00
H5520	005	0	1	04	01	H5520_005_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00	140.00							70.00						175.00	140.00	70.00	210.00	140.00	70.00
H5520	005	0	1	04	01	H5520_005_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5520	006	0	1	04	01	H5520_006_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	006	0	1	04	01	H5520_006_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5520	006	0	1	04	01	H5520_006_0	4	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00	140.00							70.00						175.00	140.00	70.00	210.00	140.00	70.00
H5520	006	0	1	04	01	H5520_006_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00						12.00	12.00	6.00	18.00	12.00	6.00
H5520	006	0	1	04	01	H5520_006_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00	80.00							40.00						80.00	80.00	40.00	120.00	80.00	40.00
H5520	007	0	1	04	01	H5520_007_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	007	0	1	04	01	H5520_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00	6.00							3.00						6.00	6.00	3.00	9.00	6.00	3.00
H5520	007	0	1	04	01	H5520_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
H5520	007	0	1	04	01	H5520_007_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00						150.00	120.00	60.00	180.00	120.00	60.00
H5520	007	0	1	04	01	H5520_007_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5520	008	0	1	04	01	H5520_008_0	5	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5520	008	0	1	04	01	H5520_008_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5520	008	0	1	04	01	H5520_008_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
H5520	008	0	1	04	01	H5520_008_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00						150.00	120.00	60.00	180.00	120.00	60.00
H5520	008	0	1	04	01	H5520_008_0	5	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5521	005	0	1	04	01	H5521_005_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5521	005	0	1	04	01	H5521_005_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5521	005	0	1	04	01	H5521_005_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H5521	005	0	1	04	01	H5521_005_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5521	005	0	1	04	01	H5521_005_0	8	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5521	006	0	1	04	01	H5521_006_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5521	006	0	1	04	01	H5521_006_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5521	006	0	1	04	01	H5521_006_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	006	0	1	04	01	H5521_006_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5521	006	0	1	04	01	H5521_006_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5521	006	0	1	04	01	H5521_006_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5521	006	0	1	04	01	H5521_006_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5521	006	0	1	04	01	H5521_006_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5521	006	0	1	04	01	H5521_006_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	006	0	1	04	01	H5521_006_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5521	008	0	1	04	01	H5521_008_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5521	008	0	1	04	01	H5521_008_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5521	008	0	1	04	01	H5521_008_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H5521	008	0	1	04	01	H5521_008_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5521	008	0	1	04	01	H5521_008_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5521	009	0	1	04	01	H5521_009_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5521	009	0	1	04	01	H5521_009_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5521	009	0	1	04	01	H5521_009_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5521	009	0	1	04	01	H5521_009_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5521	009	0	1	04	01	H5521_009_0	8	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5521	009	0	1	04	01	H5521_009_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	009	0	1	04	01	H5521_009_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5521	009	0	1	04	01	H5521_009_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5521	009	0	1	04	01	H5521_009_0	8	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5521	009	0	1	04	01	H5521_009_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	011	0	1	04	01	H5521_011_0	9	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5521	011	0	1	04	01	H5521_011_0	9	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
H5521	011	0	1	04	01	H5521_011_0	9	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
H5521	011	0	1	04	01	H5521_011_0	9	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5521	011	0	1	04	01	H5521_011_0	9	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5521	012	0	1	04	01	H5521_012_0	8	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5521	012	0	1	04	01	H5521_012_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5521	012	0	1	04	01	H5521_012_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5521	012	0	1	04	01	H5521_012_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	012	0	1	04	01	H5521_012_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5521	012	0	1	04	01	H5521_012_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5521	012	0	1	04	01	H5521_012_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5521	012	0	1	04	01	H5521_012_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5521	012	0	1	04	01	H5521_012_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5521	012	0	1	04	01	H5521_012_0	8	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5522	001	0	1	04	01	H5522_001_0	8	4	4	1	Tier 4- Specialty Drugs	010010	1	1				Tier 4- Specialty Drugs	110000000010000000000	30									30											31	Tier 4- Specialty Drugs	2	1	Tier 4- Specialty Drugs	30									30											30	Tier 4- Specialty Drugs																					
H5522	001	0	1	04	01	H5522_001_0	8	3	4	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	66.00	198.00								66.00			198.00								66.00
H5522	001	0	1	04	01	H5522_001_0	8	2	4	3	Tier 2- Preferred Brand	000001	1	2	2			Tier 2- Preferred Brand																							Tier 2- Preferred Brand			Tier 2- Preferred Brand																						Tier 2- Preferred Brand																					
H5522	001	0	1	04	01	H5522_001_0	8	3	4	3	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3- Non-Preferred Generic/Non-Preferred Brand																							Tier 3- Non-Preferred Generic/Non-Preferred Brand			Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand																					
H5522	001	0	1	04	01	H5522_001_0	8	4	4	3	Tier 4- Specialty Drugs	010010	1	1	2			Tier 4- Specialty Drugs																							Tier 4- Specialty Drugs			Tier 4- Specialty Drugs																						Tier 4- Specialty Drugs																					
H5522	001	0	1	04	01	H5522_001_0	8	1	4	3	Tier 1- Preferred Generic	001000	3	2	1		1	Tier 1- Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1- Preferred Generic	2	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5522	001	0	1	04	01	H5522_001_0	8	2	4	1	Tier 2- Preferred Brand	000001	1	2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5522	001	0	1	04	01	H5522_001_0	8	1	4	1	Tier 1- Preferred Generic	001000	3	2				Tier 1- Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1- Preferred Generic	2	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5522	002	0	1	04	01	H5522_002_0	7	4	4	1	Tier 4- Specialty Drugs	010010	1	1				Tier 4- Specialty Drugs	110000000010000000000	30									30											31	Tier 4- Specialty Drugs	2	1	Tier 4- Specialty Drugs	30									30											30	Tier 4- Specialty Drugs																					
H5522	002	0	1	04	01	H5522_002_0	7	1	4	1	Tier 1-Preferred Generic	001000	3	2				Tier 1-Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5522	002	0	1	04	01	H5522_002_0	7	2	4	3	Tier 2- Preferred Brand	000001	1	2	2			Tier 2- Preferred Brand																							Tier 2- Preferred Brand			Tier 2- Preferred Brand																						Tier 2- Preferred Brand																					
H5522	002	0	1	04	01	H5522_002_0	7	3	4	3	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3- Non-Preferred Generic/Non-Preferred Brand																							Tier 3- Non-Preferred Generic/Non-Preferred Brand			Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand																					
H5522	002	0	1	04	01	H5522_002_0	7	4	4	3	Tier 4- Specialty Drugs	010010	1	1	2			Tier 4- Specialty Drugs																							Tier 4- Specialty Drugs			Tier 4- Specialty Drugs																						Tier 4- Specialty Drugs																					
H5522	002	0	1	04	01	H5522_002_0	7	1	4	3	Tier 1-Preferred Generic	001000	3	2	1		1	Tier 1-Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5522	002	0	1	04	01	H5522_002_0	7	2	4	1	Tier 2- Preferred Brand	000001	1	2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	30.00	60.00								30.00			60.00								30.00
H5522	002	0	1	04	01	H5522_002_0	7	3	4	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H5522	003	0	1	04	01	H5522_003_0	7	4	4	1	Tier 4- Specialty Drugs	010010	1	1				Tier 4- Specialty Drugs	110000000010000000000	30									30											31	Tier 4- Specialty Drugs	2	1	Tier 4- Specialty Drugs	30									30											30	Tier 4- Specialty Drugs																					
H5522	003	0	1	04	01	H5522_003_0	7	1	4	1	Tier 1- Preferred Generic	001000	3	2				Tier 1- Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1- Preferred Generic	2	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5522	003	0	1	04	01	H5522_003_0	7	2	4	3	Tier 2- Preferred Brand	000001	1	2	2			Tier 2- Preferred Brand																							Tier 2- Preferred Brand			Tier 2- Preferred Brand																						Tier 2- Preferred Brand																					
H5522	003	0	1	04	01	H5522_003_0	7	3	4	3	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3- Non-Preferred Generic/Non-Preferred Brand																							Tier 3- Non-Preferred Generic/Non-Preferred Brand			Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand																					
H5522	003	0	1	04	01	H5522_003_0	7	4	4	3	Tier 4- Specialty Drugs	010010	1	1	2			Tier 4- Specialty Drugs																							Tier 4- Specialty Drugs			Tier 4- Specialty Drugs																						Tier 4- Specialty Drugs																					
H5522	003	0	1	04	01	H5522_003_0	7	1	4	3	Tier 1- Preferred Generic	001000	3	2	1		1	Tier 1- Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1- Preferred Generic	2	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5522	003	0	1	04	01	H5522_003_0	7	2	4	1	Tier 2- Preferred Brand	000001	1	2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5522	003	0	1	04	01	H5522_003_0	7	3	4	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	66.00	198.00								66.00			198.00								66.00
H5522	004	0	1	04	01	H5522_004_0	5	3	3	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100		2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H5522	004	0	1	04	01	H5522_004_0	5	2	3	1	Tier 2- Preferred Brand	000001		2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	33.00	66.00								33.00			66.00								33.00
H5522	004	0	1	04	01	H5522_004_0	5	4	3	1	Tier 4- Specialty Tier	010010		1				Tier 4- Specialty Tier	110000000010000000000	30									30											31	Tier 4- Specialty Tier	2	1	Tier 4- Specialty Tier	30									30											30	Tier 4- Specialty Tier																					
H5522	004	0	1	04	01	H5522_004_0	5	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	9.00	18.00								9.00			18.00								9.00
H5522	005	0	1	04	01	H5522_005_0	5	4	3	1	Tier 4- Specialty Drugs	010010		1				Tier 4- Specialty Drugs	110000000010000000000	30									30											31	Tier 4- Specialty Drugs	2	1	Tier 4- Specialty Drugs	30									30											30	Tier 4- Specialty Drugs																					
H5522	005	0	1	04	01	H5522_005_0	5	3	3	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100		2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H5522	005	0	1	04	01	H5522_005_0	5	2	3	1	Tier 2- Preferred Brand	000001		2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	30.00	60.00								30.00			60.00								30.00
H5522	005	0	1	04	01	H5522_005_0	5	1	3	1	Tier 1- Preferred Generic	001000		2				Tier 1- Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1- Preferred Generic	2	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	8.00	16.00								8.00			16.00								8.00
H5522	006	0	1	04	01	H5522_006_0	7	4	4	1	Tier 4- Specialty Drugs	010010	1	1				Tier 4- Specialty Drugs	110000000010000000000	30									30											31	Tier 4- Specialty Drugs	2	1	Tier 4- Specialty Drugs	30									30											30	Tier 4- Specialty Drugs																					
H5522	006	0	1	04	01	H5522_006_0	7	1	4	3	Tier 1-Preferred Generic	001000	3	2	1		1	Tier 1-Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5522	006	0	1	04	01	H5522_006_0	7	2	4	3	Tier 2- Preferred Brand	000001	1	2	2			Tier 2- Preferred Brand																							Tier 2- Preferred Brand			Tier 2- Preferred Brand																						Tier 2- Preferred Brand																					
H5522	006	0	1	04	01	H5522_006_0	7	3	4	3	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3- Non-Preferred Generic/Non-Preferred Brand																							Tier 3- Non-Preferred Generic/Non-Preferred Brand			Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand																					
H5522	006	0	1	04	01	H5522_006_0	7	4	4	3	Tier 4- Specialty Drugs	010010	1	1	2			Tier 4- Specialty Drugs																							Tier 4- Specialty Drugs			Tier 4- Specialty Drugs																						Tier 4- Specialty Drugs																					
H5522	006	0	1	04	01	H5522_006_0	7	2	4	1	Tier 2- Preferred Brand	000001	1	2				Tier 2- Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2- Preferred Brand	2	2	Tier 2- Preferred Brand																						Tier 2- Preferred Brand	25.00	50.00								25.00			50.00								25.00
H5522	006	0	1	04	01	H5522_006_0	7	1	4	1	Tier 1-Preferred Generic	001000	3	2				Tier 1-Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	0.00	0.00								0.00			0.00								0.00
H5522	006	0	1	04	01	H5522_006_0	7	3	4	1	Tier 3- Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3- Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3- Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3- Non-Preferred Generic/Non-Preferred Brand																						Tier 3- Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H5523	001	0	1	04	01	H5523_001_0	20	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	9.00	27.00								9.00		9.00	27.00								9.00
H5523	001	0	1	04	01	H5523_001_0	20	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5523	001	0	1	04	01	H5523_001_0	20	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H5523	001	0	1	04	01	H5523_001_0	20	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H5525	001	0	1	04	01	H5525_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5525	001	0	1	04	01	H5525_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5525	001	0	1	04	01	H5525_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5525	001	0	1	04	01	H5525_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5525	001	0	1	04	01	H5525_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5525	001	0	1	04	01	H5525_001_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5525	001	0	1	04	01	H5525_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5525	001	0	1	04	01	H5525_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5525	004	0	1	04	01	H5525_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5525	004	0	1	04	01	H5525_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5525	004	0	1	04	01	H5525_004_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5525	004	0	1	04	01	H5525_004_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H5525	004	0	1	04	01	H5525_004_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5525	004	0	1	04	01	H5525_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5525	004	0	1	04	01	H5525_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5525	004	0	1	04	01	H5525_004_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5526	003	0	1	04	01	H5526_003_0	10	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	21.00								7.00		7.00	17.50								7.00
H5526	003	0	1	04	01	H5526_003_0	10	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	25	25								25		25	21								25	Specialty Injectables																					
H5526	003	0	1	04	01	H5526_003_0	10	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																					
H5526	003	0	1	04	01	H5526_003_0	10	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H5526	004	0	1	04	01	H5526_004_0	9	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00
H5526	004	0	1	04	01	H5526_004_0	9	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	35	35								35		35	29								35	Non-Preferred Brand/Generic																					
H5526	004	0	1	04	01	H5526_004_0	9	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H5526	004	0	1	04	01	H5526_004_0	9	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H5526	007	0	1	04	01	H5526_007_0	7	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H5526	007	0	1	04	01	H5526_007_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H5526	007	0	1	04	01	H5526_007_0	7	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	21.00								7.00		7.00	17.50								7.00
H5526	007	0	1	04	01	H5526_007_0	7	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																					
H5526	007	0	1	04	01	H5526_007_0	7	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	7.00	21.00								7.00		7.00	17.50								7.00
H5526	007	0	1	04	01	H5526_007_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	75.00								30.00
H5526	007	0	1	04	01	H5526_007_0	7	3	4	3	Non-Preferred Brand/Generic	100100	1	2	2			Non-Preferred Brand/Generic																							Non-Preferred Brand/Generic			Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																					
H5526	007	0	1	04	01	H5526_007_0	7	4	4	3	Specialty Injectables	100001	1	1	2			Specialty Injectables																							Specialty Injectables			Specialty Injectables																						Specialty Injectables																					
H5526	008	0	1	04	01	H5526_008_0	9	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
H5526	008	0	1	04	01	H5526_008_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00
H5526	008	0	1	04	01	H5526_008_0	9	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H5526	008	0	1	04	01	H5526_008_0	9	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	25	25								25		25	20								25	Specialty Injectables																					
H5526	008	0	1	04	01	H5526_008_0	9	4	4	3	Specialty Injectables	100001	1	1	2			Specialty Injectables																							Specialty Injectables			Specialty Injectables																						Specialty Injectables																					
H5526	008	0	1	04	01	H5526_008_0	9	3	4	3	Non-Preferred Brand/Generic	100100	1	2	2			Non-Preferred Brand/Generic																							Non-Preferred Brand/Generic			Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																					
H5526	008	0	1	04	01	H5526_008_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5526	008	0	1	04	01	H5526_008_0	9	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	20.00								8.00
H5526	010	0	1	04	01	H5526_010_0	7	1	4	1	Formulary Generic	001000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00
H5526	010	0	1	04	01	H5526_010_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	50.00								20.00
H5526	010	0	1	04	01	H5526_010_0	7	3	4	1	Non-Preferred Brand/Generic	100100	1	2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	2	Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic	40.00	120.00								40.00		40.00	100.00								40.00
H5526	010	0	1	04	01	H5526_010_0	7	3	4	3	Non-Preferred Brand/Generic	100100	1	2	1		1	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	2	Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic	40.00	120.00								40.00		40.00	100.00								40.00
H5526	010	0	1	04	01	H5526_010_0	7	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	50.00								20.00
H5526	010	0	1	04	01	H5526_010_0	7	1	4	3	Formulary Generic	001000	1	2	1		1	Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00
H5526	010	0	1	04	01	H5526_010_0	7	4	4	1	Specialty Injectables	100001	1	1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	2	Specialty Injectables																						Specialty Injectables	40.00	120.00								40.00		40.00	100.00								40.00
H5526	010	0	1	04	01	H5526_010_0	7	4	4	3	Specialty Injectables	100001	1	1	1		1	Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	2	Specialty Injectables																						Specialty Injectables	40.00	120.00								40.00		40.00	100.00								40.00
H5528	002	0	1	04	01	H5528_002_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	002	0	1	04	01	H5528_002_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	002	0	1	04	01	H5528_002_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	15.00							5.00		5.00	10.00	10.00							5.00
H5528	002	0	1	04	01	H5528_002_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	003	0	1	04	01	H5528_003_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	003	0	1	04	01	H5528_003_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	003	0	1	04	01	H5528_003_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	003	0	1	04	01	H5528_003_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	003	0	1	04	01	H5528_003_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5528	003	0	1	04	01	H5528_003_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	003	0	1	04	01	H5528_003_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	003	0	1	04	01	H5528_003_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	005	0	1	04	01	H5528_005_0	3	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	005	0	1	04	01	H5528_005_0	3	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	15.00							5.00		5.00	10.00	10.00							5.00
H5528	005	0	1	04	01	H5528_005_0	3	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	005	0	1	04	01	H5528_005_0	3	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	008	0	1	04	01	H5528_008_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	008	0	1	04	01	H5528_008_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5528	008	0	1	04	01	H5528_008_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	008	0	1	04	01	H5528_008_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	008	0	1	04	01	H5528_008_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	008	0	1	04	01	H5528_008_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	008	0	1	04	01	H5528_008_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	008	0	1	04	01	H5528_008_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	010	0	1	04	01	H5528_010_0	3	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	010	0	1	04	01	H5528_010_0	3	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	15.00							5.00		5.00	10.00	10.00							5.00
H5528	010	0	1	04	01	H5528_010_0	3	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	010	0	1	04	01	H5528_010_0	3	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	011	0	1	04	01	H5528_011_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	011	0	1	04	01	H5528_011_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5528	011	0	1	04	01	H5528_011_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	011	0	1	04	01	H5528_011_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	011	0	1	04	01	H5528_011_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	011	0	1	04	01	H5528_011_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	011	0	1	04	01	H5528_011_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	011	0	1	04	01	H5528_011_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	015	0	1	04	01	H5528_015_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5528	015	0	1	04	01	H5528_015_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	015	0	1	04	01	H5528_015_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	015	0	1	04	01	H5528_015_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	015	0	1	04	01	H5528_015_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	015	0	1	04	01	H5528_015_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	015	0	1	04	01	H5528_015_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	015	0	1	04	01	H5528_015_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	016	0	1	04	01	H5528_016_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	016	0	1	04	01	H5528_016_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	016	0	1	04	01	H5528_016_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	016	0	1	04	01	H5528_016_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	016	0	1	04	01	H5528_016_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	016	0	1	04	01	H5528_016_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	016	0	1	04	01	H5528_016_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5528	016	0	1	04	01	H5528_016_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	017	0	1	04	01	H5528_017_0	4	1	4	1	Tier 1	001000	1	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	017	0	1	04	01	H5528_017_0	4	2	4	1	Tier 2	000001	1	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	60.00							20.00		20.00	40.00	40.00							20.00
H5528	017	0	1	04	01	H5528_017_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	1	Tier 3	50	50	50							50		50	50	50							50	Tier 3																					
H5528	017	0	1	04	01	H5528_017_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4	2	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																					
H5528	017	0	1	04	01	H5528_017_0	4	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	7.00	21.00	21.00							7.00		7.00	14.00	14.00							7.00
H5528	017	0	1	04	01	H5528_017_0	4	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5528	017	0	1	04	01	H5528_017_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5528	017	0	1	04	01	H5528_017_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5529	001	0	1	04	01	H5529_001_0	7	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H5529	001	0	1	04	01	H5529_001_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5529	001	0	1	04	01	H5529_001_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5529	001	0	1	04	01	H5529_001_0	7	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
H5529	001	0	1	04	01	H5529_001_0	7	5	4	3	Tier 5 Speciality	010010	1	1	2			Tier 5 Speciality																							Tier 5 Speciality			Tier 5 Speciality																						Tier 5 Speciality																					
H5529	001	0	1	04	01	H5529_001_0	7	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H5529	001	0	1	04	01	H5529_001_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5529	001	0	1	04	01	H5529_001_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5529	001	0	1	04	01	H5529_001_0	7	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
H5529	001	0	1	04	01	H5529_001_0	7	5	4	1	Tier 5 Speciality	010010	1	1				Tier 5 Speciality	110000000010000100100	30									30				30			30				34	Tier 5 Speciality	2	1	Tier 5 Speciality	33									33					33			33			33	Tier 5 Speciality																					
H5530	001	0	1	04	01	H5530_001_0	9	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H5530	001	0	1	04	01	H5530_001_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5530	001	0	1	04	01	H5530_001_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5530	001	0	1	04	01	H5530_001_0	9	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
H5530	001	0	1	04	01	H5530_001_0	9	5	4	1	Tier 5 Speciality	010010	1	1				Tier 5 Speciality	110000000010000100100	30									30				30			30				34	Tier 5 Speciality	2	1	Tier 5 Speciality	33									33					33			33			33	Tier 5 Speciality																					
H5530	001	0	1	04	01	H5530_001_0	9	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
H5530	001	0	1	04	01	H5530_001_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5530	001	0	1	04	01	H5530_001_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5530	001	0	1	04	01	H5530_001_0	9	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
H5530	001	0	1	04	01	H5530_001_0	9	5	4	3	Tier 5 Speciality	010010	1	1	2			Tier 5 Speciality																							Tier 5 Speciality			Tier 5 Speciality																						Tier 5 Speciality																					
H5531	001	0	1	04	01	H5531_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5531	001	0	1	04	01	H5531_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	23.00	69.00									23.00					46.00			69.00		23.00
H5531	001	0	1	04	01	H5531_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5531	001	0	1	04	01	H5531_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5531	001	0	1	04	01	H5531_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5531	002	0	1	04	01	H5531_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	002	0	1	04	01	H5531_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5531	002	0	1	04	01	H5531_002_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5531	002	0	1	04	01	H5531_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5531	002	0	1	04	01	H5531_002_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5531	002	0	1	04	01	H5531_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5531	002	0	1	04	01	H5531_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5531	002	0	1	04	01	H5531_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	002	0	1	04	01	H5531_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5531	002	0	1	04	01	H5531_002_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5531	003	0	1	04	01	H5531_003_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5531	003	0	1	04	01	H5531_003_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	23.00	69.00									23.00					46.00			69.00		23.00
H5531	003	0	1	04	01	H5531_003_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5531	003	0	1	04	01	H5531_003_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5531	003	0	1	04	01	H5531_003_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5531	004	0	1	04	01	H5531_004_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	004	0	1	04	01	H5531_004_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5531	004	0	1	04	01	H5531_004_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5531	004	0	1	04	01	H5531_004_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5531	004	0	1	04	01	H5531_004_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5531	004	0	1	04	01	H5531_004_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5531	004	0	1	04	01	H5531_004_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5531	004	0	1	04	01	H5531_004_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	004	0	1	04	01	H5531_004_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5531	004	0	1	04	01	H5531_004_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5531	005	0	1	04	01	H5531_005_0	5	1	3	1	Tier1 - Preferred Generic	001000		2				Tier1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier1 - Preferred Generic	2	2	Tier1 - Preferred Generic																						Tier1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5531	005	0	1	04	01	H5531_005_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5531	005	0	1	04	01	H5531_005_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	23.00	69.00									23.00					46.00			69.00		23.00
H5531	005	0	1	04	01	H5531_005_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5531	005	0	1	04	01	H5531_005_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5531	006	0	1	04	01	H5531_006_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5531	006	0	1	04	01	H5531_006_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5531	006	0	1	04	01	H5531_006_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5531	006	0	1	04	01	H5531_006_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5531	006	0	1	04	01	H5531_006_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	006	0	1	04	01	H5531_006_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5531	006	0	1	04	01	H5531_006_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5531	006	0	1	04	01	H5531_006_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5531	006	0	1	04	01	H5531_006_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	006	0	1	04	01	H5531_006_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5531	007	0	1	04	01	H5531_007_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5531	007	0	1	04	01	H5531_007_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5531	007	0	1	04	01	H5531_007_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5531	007	0	1	04	01	H5531_007_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5531	007	0	1	04	01	H5531_007_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	23.00	69.00									23.00					46.00			69.00		23.00
H5531	008	0	1	04	01	H5531_008_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5531	008	0	1	04	01	H5531_008_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5531	008	0	1	04	01	H5531_008_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	008	0	1	04	01	H5531_008_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5531	008	0	1	04	01	H5531_008_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5531	008	0	1	04	01	H5531_008_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5531	008	0	1	04	01	H5531_008_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5531	008	0	1	04	01	H5531_008_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	008	0	1	04	01	H5531_008_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5531	008	0	1	04	01	H5531_008_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5531	009	0	1	04	01	H5531_009_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5531	009	0	1	04	01	H5531_009_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5531	009	0	1	04	01	H5531_009_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H5531	009	0	1	04	01	H5531_009_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5531	009	0	1	04	01	H5531_009_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5531	010	0	1	04	01	H5531_010_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5531	010	0	1	04	01	H5531_010_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5531	010	0	1	04	01	H5531_010_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5531	010	0	1	04	01	H5531_010_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5531	010	0	1	04	01	H5531_010_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	010	0	1	04	01	H5531_010_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5531	010	0	1	04	01	H5531_010_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5531	010	0	1	04	01	H5531_010_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5531	010	0	1	04	01	H5531_010_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5531	010	0	1	04	01	H5531_010_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5532	001	0	1	04	01	H5532_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5532	001	0	1	04	01	H5532_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5532	001	0	1	04	01	H5532_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5532	001	0	1	04	01	H5532_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5533	002	0	1	04	01	H5533_002_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H5533	002	0	1	04	01	H5533_002_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5533	002	0	1	04	01	H5533_002_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5533	002	0	1	04	01	H5533_002_0	5	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H5533	002	0	1	04	01	H5533_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H5533	002	0	1	04	01	H5533_002_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H5533	002	0	1	04	01	H5533_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H5533	002	0	1	04	01	H5533_002_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5549	001	0	1	01	01	H5549_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5549	001	0	1	01	01	H5549_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	1	Preferred Brand	25	25								25			25								25	Preferred Brand																					
H5549	001	0	1	01	01	H5549_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	25	25								25			25								25	Non-Preferred Brand																					
H5549	001	0	1	01	01	H5549_001_0	6	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5549	001	0	1	01	01	H5549_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5549	001	0	1	01	01	H5549_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5549	001	0	1	01	01	H5549_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5549	001	0	1	01	01	H5549_001_0	6	4	4	1	Specialty	100000	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H5554	001	0	1	01	01	H5554_001_0	5	1	4	1	Generics	010000	1	2				Generics	111000000010010000000	32	90								32										90	32	Generics	2	2	Generics																						Generics	0.00	0.00								0.00			0.00								0.00
H5554	001	0	1	01	01	H5554_001_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5554	001	0	1	01	01	H5554_001_0	5	1	4	3	Generics	010000	1	2	1		1	Generics	111000000010010000000	32	90								32										90	32	Generics	2	2	Generics																						Generics	0.00	0.00								0.00			0.00								0.00
H5554	001	0	1	01	01	H5554_001_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	32	90								32										90	32	Brand	2	2	Brand																						Brand	45.00	90.00								45.00			90.00								45.00
H5575	006	0	1	01	01	H5575_006_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5575	006	0	1	01	01	H5575_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H5575	006	0	1	01	01	H5575_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H5575	007	0	1	01	01	H5575_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H5575	007	0	1	01	01	H5575_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H5575	007	0	1	01	01	H5575_007_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5576	005	0	1	02	01	H5576_005_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H5576	005	0	1	02	01	H5576_005_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	31	90								31										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H5576	005	0	1	02	01	H5576_005_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H5576	005	0	1	02	01	H5576_005_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			18.00								6.00
H5576	006	0	1	02	01	H5576_006_0	5	4	4	3	Tier 4	100000	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5576	006	0	1	02	01	H5576_006_0	5	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5576	006	0	1	02	01	H5576_006_0	5	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5576	006	0	1	02	01	H5576_006_0	5	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	1	2	Tier 1																						Tier 1	6.00	18.00								6.00			18.00								6.00
H5576	006	0	1	02	01	H5576_006_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	31	90								31										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H5576	006	0	1	02	01	H5576_006_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H5576	006	0	1	02	01	H5576_006_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			18.00								6.00
H5576	006	0	1	02	01	H5576_006_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H5576	007	0	1	02	01	H5576_007_0	7	2	2	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
H5576	007	0	1	02	01	H5576_007_0	7	3	2	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00			165.00								55.00
H5576	007	0	1	02	01	H5576_007_0	7	4	2	1	Tier 4	100000		1				Tier 4	111000000010010000000	31	90								31										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H5576	007	0	1	02	01	H5576_007_0	7	1	2	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00
H5576	009	0	1	02	01	H5576_009_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	31	90								31										90	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
H5576	009	0	1	02	01	H5576_009_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	90								31										90	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
H5576	009	0	1	02	01	H5576_009_0	5	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	90								31										90	31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			18.00								6.00
H5576	009	0	1	02	01	H5576_009_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	90								31										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
H5577	002	0	1	01	01	H5577_002_0	7	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5577	002	0	1	01	01	H5577_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H5577	002	0	1	01	01	H5577_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H5577	002	0	1	01	01	H5577_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H5578	002	0	1	01	01	H5578_002_0	19	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5578	002	0	1	01	01	H5578_002_0	19	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5578	002	0	1	01	01	H5578_002_0	19	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5578	002	0	1	01	01	H5578_002_0	19	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5578	002	0	1	01	01	H5578_002_0	19	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5578	002	0	1	01	01	H5578_002_0	19	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5578	002	0	1	01	01	H5578_002_0	19	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5578	002	0	1	01	01	H5578_002_0	19	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5578	006	0	1	01	01	H5578_006_0	19	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						0.00			15.00		5.00
H5578	006	0	1	01	01	H5578_006_0	19	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5578	006	0	1	01	01	H5578_006_0	19	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5578	006	0	1	01	01	H5578_006_0	19	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5578	006	0	1	01	01	H5578_006_0	19	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5578	006	0	1	01	01	H5578_006_0	19	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5578	006	0	1	01	01	H5578_006_0	19	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5578	006	0	1	01	01	H5578_006_0	19	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5588	002	0	1	01	01	H5588_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5588	002	0	1	01	01	H5588_002_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H5588	002	0	1	01	01	H5588_002_0	7	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H5588	002	0	1	01	01	H5588_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H5590	001	0	1	01	01	H5590_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5590	001	0	1	01	01	H5590_001_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	42.00	126.00								42.00			126.00								42.00
H5590	001	0	1	01	01	H5590_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
H5590	001	0	1	01	01	H5590_001_0	7	4	4	1	Injectable	000001	1	2				Injectable	111000000010010000000	30	90								30										90	31	Injectable	2	2	Injectable																						Injectable	42.00	126.00								42.00			126.00								42.00
H5591	001	0	1	02	01	H5591_001_0	11	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5591	001	0	1	02	01	H5591_001_0	11	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5591	001	0	1	02	01	H5591_001_0	11	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010111000000	30	90								30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00
H5591	001	0	1	02	01	H5591_001_0	11	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5591	001	0	1	02	01	H5591_001_0	11	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010111000000	30	90								30		30	60							90	31	Tier 4	2	1	Tier 4	25	25								25		25	25	25							25	Tier 4																					
H5591	001	0	1	02	01	H5591_001_0	11	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010111000000	30	90								30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50	110.00							55.00
H5591	001	0	1	02	01	H5591_001_0	11	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010111000000	30	90								30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00		35.00	87.50	70.00							35.00
H5591	001	0	1	02	01	H5591_001_0	11	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010111000000	30	90								30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00
H5591	002	0	1	01	01	H5591_002_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010111000000	30	90								30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00
H5591	002	0	1	01	01	H5591_002_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010111000000	30	90								30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50	110.00							55.00
H5591	002	0	1	01	01	H5591_002_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010111000000	30	90								30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00		35.00	87.50	70.00							35.00
H5591	002	0	1	01	01	H5591_002_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5591	002	0	1	01	01	H5591_002_0	8	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5591	002	0	1	01	01	H5591_002_0	8	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5591	002	0	1	01	01	H5591_002_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010111000000	30	90								30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00
H5591	002	0	1	01	01	H5591_002_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010111000000	30	90								30		30	60							90	31	Tier 4	2	1	Tier 4	25	25								25		25	25	25							25	Tier 4																					
H5594	001	0	1	02	01	H5594_001_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5594	001	0	1	02	01	H5594_001_0	8	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5594	001	0	1	02	01	H5594_001_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5594	001	0	1	02	01	H5594_001_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	001	0	1	02	01	H5594_001_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	001	0	1	02	01	H5594_001_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			150.00								75.00
H5594	001	0	1	02	01	H5594_001_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	001	0	1	02	01	H5594_001_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			70.00								35.00
H5594	002	0	1	02	01	H5594_002_0	8	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5594	002	0	1	02	01	H5594_002_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5594	002	0	1	02	01	H5594_002_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	002	0	1	02	01	H5594_002_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5594	002	0	1	02	01	H5594_002_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	002	0	1	02	01	H5594_002_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00
H5594	002	0	1	02	01	H5594_002_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00			100.00								50.00
H5594	002	0	1	02	01	H5594_002_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	005	0	1	02	01	H5594_005_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	005	0	1	02	01	H5594_005_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			140.00								70.00
H5594	005	0	1	02	01	H5594_005_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	005	0	1	02	01	H5594_005_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			70.00								35.00
H5594	006	0	1	02	01	H5594_006_0	8	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5594	006	0	1	02	01	H5594_006_0	8	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5594	006	0	1	02	01	H5594_006_0	8	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	006	0	1	02	01	H5594_006_0	8	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5594	006	0	1	02	01	H5594_006_0	8	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	006	0	1	02	01	H5594_006_0	8	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			70.00								35.00
H5594	006	0	1	02	01	H5594_006_0	8	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			140.00								70.00
H5594	006	0	1	02	01	H5594_006_0	8	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	007	0	1	02	01	H5594_007_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	007	0	1	02	01	H5594_007_0	9	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			140.00								70.00
H5594	007	0	1	02	01	H5594_007_0	9	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	007	0	1	02	01	H5594_007_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			70.00								35.00
H5594	008	0	1	02	01	H5594_008_0	9	2	4	3	Tier 2	000001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H5594	008	0	1	02	01	H5594_008_0	9	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	008	0	1	02	01	H5594_008_0	9	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			70.00								35.00
H5594	008	0	1	02	01	H5594_008_0	9	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			140.00								70.00
H5594	008	0	1	02	01	H5594_008_0	9	3	4	3	Tier 3	100000	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H5594	008	0	1	02	01	H5594_008_0	9	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
H5594	008	0	1	02	01	H5594_008_0	9	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5594	008	0	1	02	01	H5594_008_0	9	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	009	0	1	02	01	H5594_009_0	10	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5594	009	0	1	02	01	H5594_009_0	10	3	4	1	Tier 3	100000	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			170.00								85.00
H5594	009	0	1	02	01	H5594_009_0	10	2	4	1	Tier 2	000001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	45.00	135.00								45.00			90.00								45.00
H5594	009	0	1	02	01	H5594_009_0	10	1	4	1	Tier 1	010000	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H5608	003	0	1	01	01	H5608_003_0	7	1	4	3	1	011100	1	2	1		1	1	111000000001000000000	31	90									10										31	1	2	2	1																						1	10.00	20.00									10.00										10.00
H5608	003	0	1	01	01	H5608_003_0	7	2	4	1	2	100011	1	2				2	111000000001000000000	31	90									10										31	2	2	2	2																						2	35.00	70.00									35.00										35.00
H5608	003	0	1	01	01	H5608_003_0	7	1	4	1	1	011100	1	2				1	111000000001000000000	31	90									10										31	1	2	2	1																						1	10.00	20.00									10.00										10.00
H5608	003	0	1	01	01	H5608_003_0	7	2	4	3	2	100011	1	2	2			2																							2			2																						2																					
H5609	001	0	1	01	01	H5609_001_0	11	5	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5609	001	0	1	01	01	H5609_001_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5609	001	0	1	01	01	H5609_001_0	11	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5609	001	0	1	01	01	H5609_001_0	11	4	4	3	Injectible	010010	1	2	2			Injectible																							Injectible			Injectible																						Injectible																					
H5609	001	0	1	01	01	H5609_001_0	11	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5609	001	0	1	01	01	H5609_001_0	11	4	4	1	Injectible	010010	1	2				Injectible	111000000010010000000	30	90								30										90	31	Injectible	2	1	Injectible	25	25								25			25								25	Injectible																					
H5609	001	0	1	01	01	H5609_001_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00			80.00								40.00
H5609	001	0	1	01	01	H5609_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			40.00								20.00
H5609	001	0	1	01	01	H5609_001_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5609	001	0	1	01	01	H5609_001_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5619	001	0	1	01	01	H5619_001_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						0.00			15.00		5.00
H5619	001	0	1	01	01	H5619_001_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5619	001	0	1	01	01	H5619_001_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5619	001	0	1	01	01	H5619_001_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5619	001	0	1	01	01	H5619_001_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5619	001	0	1	01	01	H5619_001_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5619	001	0	1	01	01	H5619_001_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5619	001	0	1	01	01	H5619_001_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5619	004	0	1	01	01	H5619_004_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5619	004	0	1	01	01	H5619_004_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5619	004	0	1	01	01	H5619_004_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5619	004	0	1	01	01	H5619_004_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5619	004	0	1	01	01	H5619_004_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5619	004	0	1	01	01	H5619_004_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5619	004	0	1	01	01	H5619_004_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						0.00			15.00		5.00
H5619	004	0	1	01	01	H5619_004_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5619	007	0	1	01	01	H5619_007_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5619	007	0	1	01	01	H5619_007_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5619	007	0	1	01	01	H5619_007_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5619	007	0	1	01	01	H5619_007_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5619	007	0	1	01	01	H5619_007_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5619	007	0	1	01	01	H5619_007_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5619	007	0	1	01	01	H5619_007_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5619	007	0	1	01	01	H5619_007_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5619	008	0	1	01	01	H5619_008_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5619	008	0	1	01	01	H5619_008_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5619	008	0	1	01	01	H5619_008_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5619	008	0	1	01	01	H5619_008_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5619	008	0	1	01	01	H5619_008_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5619	008	0	1	01	01	H5619_008_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5619	008	0	1	01	01	H5619_008_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5619	008	0	1	01	01	H5619_008_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5628	001	0	1	01	01	H5628_001_0	6	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5628	001	0	1	01	01	H5628_001_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00			117.00								39.00
H5628	001	0	1	01	01	H5628_001_0	6	3	3	1	Non-Preferred Brand	000100		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
H5628	001	0	1	01	01	H5628_001_0	6	4	3	1	Specialty Drugs	010010		1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H5628	002	0	1	01	01	H5628_002_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5628	002	0	1	01	01	H5628_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			60.00								20.00
H5628	002	0	1	01	01	H5628_002_0	8	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H5628	002	0	1	01	01	H5628_002_0	8	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H5628	006	0	1	01	01	H5628_006_0	5	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5628	006	0	1	01	01	H5628_006_0	5	3	3	1	Non-Preferred Brand	000100		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
H5628	006	0	1	01	01	H5628_006_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00			117.00								39.00
H5628	006	0	1	01	01	H5628_006_0	5	4	3	1	Specialty Drugs	010010		1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H5640	001	0	1	01	01	H5640_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5640	001	0	1	01	01	H5640_001_0	7	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	1	Brand	25	25								25		25	25								25	Brand																					
H5640	001	0	1	01	01	H5640_001_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5640	001	0	1	01	01	H5640_001_0	7	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5649	001	0	1	01	01	H5649_001_0	7	4	4	1	Specialty Drugs	111111	1	1				Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Specialty Drugs	2	1	Specialty Drugs	20	20								20		20	20								20	Specialty Drugs																					
H5649	001	0	1	01	01	H5649_001_0	7	1	4	1	Generic	011100	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5649	001	0	1	01	01	H5649_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00		10.00	30.00								10.00
H5649	001	0	1	01	01	H5649_001_0	7	3	4	1	Brand	100010	3	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00		30.00	90.00								30.00
H5652	001	0	1	37	05	H5652_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5652	001	0	1	37	05	H5652_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5652	001	0	1	37	05	H5652_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5652	001	0	1	37	05	H5652_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5652	003	0	1	37	05	H5652_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5652	003	0	1	37	05	H5652_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5652	003	0	1	37	05	H5652_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5652	003	0	1	37	05	H5652_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5652	004	0	1	37	05	H5652_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5652	004	0	1	37	05	H5652_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5652	004	0	1	37	05	H5652_004_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5652	004	0	1	37	05	H5652_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5656	001	0	1	01	01	H5656_001_0	5	2	4	1	Preferred  Brand	000001	1	2				Preferred  Brand	111000000010000000000	31	90								31											31	Preferred  Brand	2	2	Preferred  Brand																						Preferred  Brand	30.00	75.00								30.00											30.00
H5656	001	0	1	01	01	H5656_001_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5656	001	0	1	01	01	H5656_001_0	5	2	4	3	Preferred  Brand	000001	1	2	2			Preferred  Brand																							Preferred  Brand			Preferred  Brand																						Preferred  Brand																					
H5656	001	0	1	01	01	H5656_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5656	001	0	1	01	01	H5656_001_0	5	4	4	3	Speciality	110001	1	1	2			Speciality																							Speciality			Speciality																						Speciality																					
H5656	001	0	1	01	01	H5656_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5656	001	0	1	01	01	H5656_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H5656	001	0	1	01	01	H5656_001_0	5	4	4	1	Speciality	110001	1	1				Speciality	110000000010000000000	31									31											31	Speciality	2	1	Speciality	25									25											25	Speciality																					
H5656	004	0	1	01	01	H5656_004_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5656	004	0	1	01	01	H5656_004_0	6	4	4	1	Speciality	110001	1	1				Speciality	110000000010000000000	31									31											31	Speciality	2	1	Speciality	25									25											25	Speciality																					
H5656	004	0	1	01	01	H5656_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H5656	004	0	1	01	01	H5656_004_0	6	2	4	1	Preferred  Brand	000001	1	2				Preferred  Brand	111000000010000000000	31	90								31											31	Preferred  Brand	2	2	Preferred  Brand																						Preferred  Brand	30.00	75.00								30.00											30.00
H5656	009	0	1	01	01	H5656_009_0	6	4	4	3	Speciality	110001	1	1	2			Speciality																							Speciality			Speciality																						Speciality																					
H5656	009	0	1	01	01	H5656_009_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5656	009	0	1	01	01	H5656_009_0	6	2	4	3	Preferred  Brand	000001	1	2	2			Preferred  Brand																							Preferred  Brand			Preferred  Brand																						Preferred  Brand																					
H5656	009	0	1	01	01	H5656_009_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5656	009	0	1	01	01	H5656_009_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H5656	009	0	1	01	01	H5656_009_0	6	2	4	1	Preferred  Brand	000001	1	2				Preferred  Brand	111000000010000000000	31	90								31											31	Preferred  Brand	2	2	Preferred  Brand																						Preferred  Brand	30.00	75.00								30.00											30.00
H5656	009	0	1	01	01	H5656_009_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5656	009	0	1	01	01	H5656_009_0	6	4	4	1	Speciality	110001	1	1				Speciality	110000000010000000000	31									31											31	Speciality	2	1	Speciality	25									25											25	Speciality																					
H5657	004	0	1	09	04	H5657_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5657	004	0	1	09	04	H5657_004_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5657	004	0	1	09	04	H5657_004_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5657	004	0	1	09	04	H5657_004_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5657	004	0	1	09	04	H5657_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5657	004	0	1	09	04	H5657_004_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5657	004	0	1	09	04	H5657_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5657	004	0	1	09	04	H5657_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5657	005	0	1	09	04	H5657_005_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5657	005	0	1	09	04	H5657_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5657	005	0	1	09	04	H5657_005_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5657	005	0	1	09	04	H5657_005_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5657	005	0	1	09	04	H5657_005_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5657	005	0	1	09	04	H5657_005_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5657	005	0	1	09	04	H5657_005_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H5657	005	0	1	09	04	H5657_005_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5665	002	0	1	01	01	H5665_002_0	9	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	24.00								8.00
H5665	002	0	1	01	01	H5665_002_0	9	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
H5665	002	0	1	01	01	H5665_002_0	9	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
H5665	002	0	1	01	01	H5665_002_0	9	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	37.00	111.00								37.00		37.00	111.00								37.00
H5678	001	0	1	37	05	H5678_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5678	001	0	1	37	05	H5678_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5678	001	0	1	37	05	H5678_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5678	001	0	1	37	05	H5678_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5678	003	0	1	37	05	H5678_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5678	003	0	1	37	05	H5678_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5678	003	0	1	37	05	H5678_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5678	003	0	1	37	05	H5678_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5678	004	0	1	37	05	H5678_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5678	004	0	1	37	05	H5678_004_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5678	004	0	1	37	05	H5678_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5678	004	0	1	37	05	H5678_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5679	001	0	1	01	01	H5679_001_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5679	001	0	1	01	01	H5679_001_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5679	001	0	1	01	01	H5679_001_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5679	001	0	1	01	01	H5679_001_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5679	001	0	1	01	01	H5679_001_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5679	001	0	1	01	01	H5679_001_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5679	001	0	1	01	01	H5679_001_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5679	001	0	1	01	01	H5679_001_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5679	001	0	1	01	01	H5679_001_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5679	001	0	1	01	01	H5679_001_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5679	002	0	1	01	01	H5679_002_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5679	002	0	1	01	01	H5679_002_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H5679	002	0	1	01	01	H5679_002_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H5679	002	0	1	01	01	H5679_002_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5679	002	0	1	01	01	H5679_002_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5679	002	0	1	01	01	H5679_002_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5679	002	0	1	01	01	H5679_002_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H5679	002	0	1	01	01	H5679_002_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5679	002	0	1	01	01	H5679_002_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5679	002	0	1	01	01	H5679_002_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5696	001	0	1	01	01	H5696_001_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	001	0	1	01	01	H5696_001_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5696	001	0	1	01	01	H5696_001_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5696	001	0	1	01	01	H5696_001_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			200.00								70.00
H5696	001	0	1	01	01	H5696_001_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	001	0	1	01	01	H5696_001_0	9	4	4	1	Injectable  Specialty	010010	1	1				Injectable  Specialty	111000000010010000000	30	90								30										90	31	Injectable  Specialty	2	1	Injectable  Specialty	33	33								33			33								33	Injectable  Specialty																					
H5696	001	0	1	01	01	H5696_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			50.00								20.00
H5696	001	0	1	01	01	H5696_001_0	9	4	4	3	Injectable  Specialty	010010	1	1	2			Injectable  Specialty																							Injectable  Specialty			Injectable  Specialty																						Injectable  Specialty																					
H5696	002	0	1	01	01	H5696_002_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	8.00								4.00			4.00								4.00
H5696	002	0	1	01	01	H5696_002_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			215.00								75.00
H5696	002	0	1	01	01	H5696_002_0	10	4	4	1	Injectable  Specialty	010010	1	1				Injectable  Specialty	111000000010010000000	30	90								30										90	31	Injectable  Specialty	2	1	Injectable  Specialty	33	33								33			33								33	Injectable  Specialty																					
H5696	002	0	1	01	01	H5696_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			65.00								25.00
H5696	003	0	1	01	01	H5696_003_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5696	003	0	1	01	01	H5696_003_0	8	4	4	3	Injectable  Specialty	010010	1	1	2			Injectable  Specialty																							Injectable  Specialty			Injectable  Specialty																						Injectable  Specialty																					
H5696	003	0	1	01	01	H5696_003_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5696	003	0	1	01	01	H5696_003_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	003	0	1	01	01	H5696_003_0	8	4	4	1	Injectable  Specialty	010010	1	1				Injectable  Specialty	111000000010010000000	30	90								30										90	31	Injectable  Specialty	2	1	Injectable  Specialty	33	33								33			33								33	Injectable  Specialty																					
H5696	003	0	1	01	01	H5696_003_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			185.00								65.00
H5696	003	0	1	01	01	H5696_003_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			50.00								20.00
H5696	003	0	1	01	01	H5696_003_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	004	0	1	01	01	H5696_004_0	9	4	4	1	Injectable  Specialty	010010	1	1				Injectable  Specialty	111000000010010000000	30	90								30										90	31	Injectable  Specialty	2	1	Injectable  Specialty	33	33								33			33								33	Injectable  Specialty																					
H5696	004	0	1	01	01	H5696_004_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	004	0	1	01	01	H5696_004_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			80.00								30.00
H5696	004	0	1	01	01	H5696_004_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			200.00								70.00
H5696	022	0	1	01	01	H5696_022_0	12	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5696	022	0	1	01	01	H5696_022_0	12	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5696	022	0	1	01	01	H5696_022_0	12	4	4	3	Injectable and Specialty	010010	1	1	2			Injectable and Specialty																							Injectable and Specialty			Injectable and Specialty																						Injectable and Specialty																					
H5696	022	0	1	01	01	H5696_022_0	12	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	022	0	1	01	01	H5696_022_0	12	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5696	022	0	1	01	01	H5696_022_0	12	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			80.00								30.00
H5696	022	0	1	01	01	H5696_022_0	12	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			200.00								70.00
H5696	022	0	1	01	01	H5696_022_0	12	4	4	1	Injectable and Specialty	010010	1	1				Injectable and Specialty	111000000010010000000	30	90								30										90	31	Injectable and Specialty	2	1	Injectable and Specialty	33	33								33			33								33	Injectable and Specialty																					
H5697	001	0	1	37	05	H5697_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5697	001	0	1	37	05	H5697_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5697	001	0	1	37	05	H5697_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5697	001	0	1	37	05	H5697_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5697	003	0	1	37	05	H5697_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5697	003	0	1	37	05	H5697_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5697	003	0	1	37	05	H5697_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5697	003	0	1	37	05	H5697_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5697	004	0	1	37	05	H5697_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5697	004	0	1	37	05	H5697_004_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5697	004	0	1	37	05	H5697_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5697	004	0	1	37	05	H5697_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5698	002	0	1	01	01	H5698_002_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	002	0	1	01	01	H5698_002_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	002	0	1	01	01	H5698_002_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	002	0	1	01	01	H5698_002_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	002	0	1	01	01	H5698_002_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	002	0	1	01	01	H5698_002_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	002	0	1	01	01	H5698_002_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	002	0	1	01	01	H5698_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	002	0	1	01	01	H5698_002_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	002	0	1	01	01	H5698_002_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	005	0	1	01	01	H5698_005_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	005	0	1	01	01	H5698_005_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	005	0	1	01	01	H5698_005_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	005	0	1	01	01	H5698_005_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	005	0	1	01	01	H5698_005_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	005	0	1	01	01	H5698_005_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	005	0	1	01	01	H5698_005_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	005	0	1	01	01	H5698_005_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	005	0	1	01	01	H5698_005_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	005	0	1	01	01	H5698_005_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	017	0	1	01	01	H5698_017_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	017	0	1	01	01	H5698_017_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	017	0	1	01	01	H5698_017_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	017	0	1	01	01	H5698_017_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	017	0	1	01	01	H5698_017_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	017	0	1	01	01	H5698_017_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	017	0	1	01	01	H5698_017_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	017	0	1	01	01	H5698_017_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	017	0	1	01	01	H5698_017_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	017	0	1	01	01	H5698_017_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	018	0	1	01	01	H5698_018_0	7	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	018	0	1	01	01	H5698_018_0	7	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	018	0	1	01	01	H5698_018_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	018	0	1	01	01	H5698_018_0	7	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	018	0	1	01	01	H5698_018_0	7	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	018	0	1	01	01	H5698_018_0	7	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	018	0	1	01	01	H5698_018_0	7	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	018	0	1	01	01	H5698_018_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	018	0	1	01	01	H5698_018_0	7	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	018	0	1	01	01	H5698_018_0	7	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	020	0	1	01	01	H5698_020_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	020	0	1	01	01	H5698_020_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	020	0	1	01	01	H5698_020_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	020	0	1	01	01	H5698_020_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	020	0	1	01	01	H5698_020_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	020	0	1	01	01	H5698_020_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	020	0	1	01	01	H5698_020_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	020	0	1	01	01	H5698_020_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	020	0	1	01	01	H5698_020_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	020	0	1	01	01	H5698_020_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	021	0	1	01	01	H5698_021_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	021	0	1	01	01	H5698_021_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	021	0	1	01	01	H5698_021_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	021	0	1	01	01	H5698_021_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	021	0	1	01	01	H5698_021_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	021	0	1	01	01	H5698_021_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	021	0	1	01	01	H5698_021_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	021	0	1	01	01	H5698_021_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	021	0	1	01	01	H5698_021_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	021	0	1	01	01	H5698_021_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	028	0	1	01	01	H5698_028_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	028	0	1	01	01	H5698_028_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	028	0	1	01	01	H5698_028_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	028	0	1	01	01	H5698_028_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	028	0	1	01	01	H5698_028_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	028	0	1	01	01	H5698_028_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	028	0	1	01	01	H5698_028_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	028	0	1	01	01	H5698_028_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	028	0	1	01	01	H5698_028_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	028	0	1	01	01	H5698_028_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	029	0	1	01	01	H5698_029_0	7	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	029	0	1	01	01	H5698_029_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	029	0	1	01	01	H5698_029_0	7	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	029	0	1	01	01	H5698_029_0	7	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	029	0	1	01	01	H5698_029_0	7	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	029	0	1	01	01	H5698_029_0	7	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	029	0	1	01	01	H5698_029_0	7	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	029	0	1	01	01	H5698_029_0	7	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	029	0	1	01	01	H5698_029_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	029	0	1	01	01	H5698_029_0	7	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	036	0	1	01	01	H5698_036_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	036	0	1	01	01	H5698_036_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	036	0	1	01	01	H5698_036_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	036	0	1	01	01	H5698_036_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	036	0	1	01	01	H5698_036_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	036	0	1	01	01	H5698_036_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	036	0	1	01	01	H5698_036_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	036	0	1	01	01	H5698_036_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	036	0	1	01	01	H5698_036_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	036	0	1	01	01	H5698_036_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	037	0	1	01	01	H5698_037_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	037	0	1	01	01	H5698_037_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	037	0	1	01	01	H5698_037_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	037	0	1	01	01	H5698_037_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	037	0	1	01	01	H5698_037_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	037	0	1	01	01	H5698_037_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	037	0	1	01	01	H5698_037_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	037	0	1	01	01	H5698_037_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	037	0	1	01	01	H5698_037_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	037	0	1	01	01	H5698_037_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	056	0	1	01	01	H5698_056_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	056	0	1	01	01	H5698_056_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	056	0	1	01	01	H5698_056_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	056	0	1	01	01	H5698_056_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	056	0	1	01	01	H5698_056_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	056	0	1	01	01	H5698_056_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	056	0	1	01	01	H5698_056_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	056	0	1	01	01	H5698_056_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	056	0	1	01	01	H5698_056_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	056	0	1	01	01	H5698_056_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	057	0	1	01	01	H5698_057_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	057	0	1	01	01	H5698_057_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	057	0	1	01	01	H5698_057_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	057	0	1	01	01	H5698_057_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	057	0	1	01	01	H5698_057_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	057	0	1	01	01	H5698_057_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	057	0	1	01	01	H5698_057_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	057	0	1	01	01	H5698_057_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	057	0	1	01	01	H5698_057_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	057	0	1	01	01	H5698_057_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	059	0	1	01	01	H5698_059_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	059	0	1	01	01	H5698_059_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	059	0	1	01	01	H5698_059_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	059	0	1	01	01	H5698_059_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	059	0	1	01	01	H5698_059_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	059	0	1	01	01	H5698_059_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	059	0	1	01	01	H5698_059_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	059	0	1	01	01	H5698_059_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	059	0	1	01	01	H5698_059_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	059	0	1	01	01	H5698_059_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	060	0	1	01	01	H5698_060_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	060	0	1	01	01	H5698_060_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	060	0	1	01	01	H5698_060_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	060	0	1	01	01	H5698_060_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	060	0	1	01	01	H5698_060_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	060	0	1	01	01	H5698_060_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	060	0	1	01	01	H5698_060_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	060	0	1	01	01	H5698_060_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	060	0	1	01	01	H5698_060_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	060	0	1	01	01	H5698_060_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	061	0	1	01	01	H5698_061_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	061	0	1	01	01	H5698_061_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	061	0	1	01	01	H5698_061_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	061	0	1	01	01	H5698_061_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	061	0	1	01	01	H5698_061_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	061	0	1	01	01	H5698_061_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	061	0	1	01	01	H5698_061_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	061	0	1	01	01	H5698_061_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	061	0	1	01	01	H5698_061_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	061	0	1	01	01	H5698_061_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	062	0	1	01	01	H5698_062_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	062	0	1	01	01	H5698_062_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	062	0	1	01	01	H5698_062_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	062	0	1	01	01	H5698_062_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	062	0	1	01	01	H5698_062_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	062	0	1	01	01	H5698_062_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	062	0	1	01	01	H5698_062_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	062	0	1	01	01	H5698_062_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	062	0	1	01	01	H5698_062_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	062	0	1	01	01	H5698_062_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	063	0	1	01	01	H5698_063_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	063	0	1	01	01	H5698_063_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	063	0	1	01	01	H5698_063_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	063	0	1	01	01	H5698_063_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	063	0	1	01	01	H5698_063_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	063	0	1	01	01	H5698_063_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	063	0	1	01	01	H5698_063_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	063	0	1	01	01	H5698_063_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	063	0	1	01	01	H5698_063_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	063	0	1	01	01	H5698_063_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	064	0	1	01	01	H5698_064_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	064	0	1	01	01	H5698_064_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	064	0	1	01	01	H5698_064_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	064	0	1	01	01	H5698_064_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	064	0	1	01	01	H5698_064_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	064	0	1	01	01	H5698_064_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	064	0	1	01	01	H5698_064_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	064	0	1	01	01	H5698_064_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	064	0	1	01	01	H5698_064_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	064	0	1	01	01	H5698_064_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	065	0	1	01	01	H5698_065_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	065	0	1	01	01	H5698_065_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	065	0	1	01	01	H5698_065_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	065	0	1	01	01	H5698_065_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	065	0	1	01	01	H5698_065_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	065	0	1	01	01	H5698_065_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	065	0	1	01	01	H5698_065_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	065	0	1	01	01	H5698_065_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	065	0	1	01	01	H5698_065_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	065	0	1	01	01	H5698_065_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	066	0	1	01	01	H5698_066_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	066	0	1	01	01	H5698_066_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	066	0	1	01	01	H5698_066_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	066	0	1	01	01	H5698_066_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	066	0	1	01	01	H5698_066_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	066	0	1	01	01	H5698_066_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	066	0	1	01	01	H5698_066_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	066	0	1	01	01	H5698_066_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	066	0	1	01	01	H5698_066_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	066	0	1	01	01	H5698_066_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	067	0	1	01	01	H5698_067_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	067	0	1	01	01	H5698_067_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	067	0	1	01	01	H5698_067_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	067	0	1	01	01	H5698_067_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	067	0	1	01	01	H5698_067_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	067	0	1	01	01	H5698_067_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	067	0	1	01	01	H5698_067_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	067	0	1	01	01	H5698_067_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	067	0	1	01	01	H5698_067_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	067	0	1	01	01	H5698_067_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	068	0	1	01	01	H5698_068_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	068	0	1	01	01	H5698_068_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	068	0	1	01	01	H5698_068_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	068	0	1	01	01	H5698_068_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	068	0	1	01	01	H5698_068_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	068	0	1	01	01	H5698_068_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	068	0	1	01	01	H5698_068_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	068	0	1	01	01	H5698_068_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	068	0	1	01	01	H5698_068_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	068	0	1	01	01	H5698_068_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	069	0	1	01	01	H5698_069_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	069	0	1	01	01	H5698_069_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	069	0	1	01	01	H5698_069_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	069	0	1	01	01	H5698_069_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	069	0	1	01	01	H5698_069_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	069	0	1	01	01	H5698_069_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	069	0	1	01	01	H5698_069_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	069	0	1	01	01	H5698_069_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	069	0	1	01	01	H5698_069_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	069	0	1	01	01	H5698_069_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	070	0	1	01	01	H5698_070_0	4	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	070	0	1	01	01	H5698_070_0	4	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	070	0	1	01	01	H5698_070_0	4	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	070	0	1	01	01	H5698_070_0	4	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	070	0	1	01	01	H5698_070_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	070	0	1	01	01	H5698_070_0	4	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	070	0	1	01	01	H5698_070_0	4	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	070	0	1	01	01	H5698_070_0	4	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	070	0	1	01	01	H5698_070_0	4	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	070	0	1	01	01	H5698_070_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	071	0	1	01	01	H5698_071_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	071	0	1	01	01	H5698_071_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	071	0	1	01	01	H5698_071_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	071	0	1	01	01	H5698_071_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	071	0	1	01	01	H5698_071_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	071	0	1	01	01	H5698_071_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	071	0	1	01	01	H5698_071_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	071	0	1	01	01	H5698_071_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	071	0	1	01	01	H5698_071_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	071	0	1	01	01	H5698_071_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	072	0	1	01	01	H5698_072_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	072	0	1	01	01	H5698_072_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	072	0	1	01	01	H5698_072_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	072	0	1	01	01	H5698_072_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	072	0	1	01	01	H5698_072_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	072	0	1	01	01	H5698_072_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	072	0	1	01	01	H5698_072_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	072	0	1	01	01	H5698_072_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	072	0	1	01	01	H5698_072_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	072	0	1	01	01	H5698_072_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	073	0	1	01	01	H5698_073_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	073	0	1	01	01	H5698_073_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	073	0	1	01	01	H5698_073_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	073	0	1	01	01	H5698_073_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	073	0	1	01	01	H5698_073_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	073	0	1	01	01	H5698_073_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	073	0	1	01	01	H5698_073_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	073	0	1	01	01	H5698_073_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	073	0	1	01	01	H5698_073_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	073	0	1	01	01	H5698_073_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	074	0	1	01	01	H5698_074_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	074	0	1	01	01	H5698_074_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	074	0	1	01	01	H5698_074_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	074	0	1	01	01	H5698_074_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	074	0	1	01	01	H5698_074_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	074	0	1	01	01	H5698_074_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	074	0	1	01	01	H5698_074_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	074	0	1	01	01	H5698_074_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	074	0	1	01	01	H5698_074_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	074	0	1	01	01	H5698_074_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	075	0	1	01	01	H5698_075_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	075	0	1	01	01	H5698_075_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	075	0	1	01	01	H5698_075_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	075	0	1	01	01	H5698_075_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	075	0	1	01	01	H5698_075_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	075	0	1	01	01	H5698_075_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	075	0	1	01	01	H5698_075_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	075	0	1	01	01	H5698_075_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	075	0	1	01	01	H5698_075_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	075	0	1	01	01	H5698_075_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	076	0	1	01	01	H5698_076_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	076	0	1	01	01	H5698_076_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	076	0	1	01	01	H5698_076_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	076	0	1	01	01	H5698_076_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	076	0	1	01	01	H5698_076_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	076	0	1	01	01	H5698_076_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	076	0	1	01	01	H5698_076_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	076	0	1	01	01	H5698_076_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	076	0	1	01	01	H5698_076_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	076	0	1	01	01	H5698_076_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	086	0	1	01	01	H5698_086_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	086	0	1	01	01	H5698_086_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	086	0	1	01	01	H5698_086_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	086	0	1	01	01	H5698_086_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	086	0	1	01	01	H5698_086_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	086	0	1	01	01	H5698_086_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	086	0	1	01	01	H5698_086_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	086	0	1	01	01	H5698_086_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	086	0	1	01	01	H5698_086_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	086	0	1	01	01	H5698_086_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	087	0	1	01	01	H5698_087_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	087	0	1	01	01	H5698_087_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	087	0	1	01	01	H5698_087_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	087	0	1	01	01	H5698_087_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	087	0	1	01	01	H5698_087_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	087	0	1	01	01	H5698_087_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	087	0	1	01	01	H5698_087_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	087	0	1	01	01	H5698_087_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	087	0	1	01	01	H5698_087_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	087	0	1	01	01	H5698_087_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	088	0	1	01	01	H5698_088_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	088	0	1	01	01	H5698_088_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	088	0	1	01	01	H5698_088_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	088	0	1	01	01	H5698_088_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	088	0	1	01	01	H5698_088_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	088	0	1	01	01	H5698_088_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	088	0	1	01	01	H5698_088_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	088	0	1	01	01	H5698_088_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	088	0	1	01	01	H5698_088_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	088	0	1	01	01	H5698_088_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	089	0	1	01	01	H5698_089_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	089	0	1	01	01	H5698_089_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	089	0	1	01	01	H5698_089_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	089	0	1	01	01	H5698_089_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	089	0	1	01	01	H5698_089_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	089	0	1	01	01	H5698_089_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	089	0	1	01	01	H5698_089_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	089	0	1	01	01	H5698_089_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	089	0	1	01	01	H5698_089_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	089	0	1	01	01	H5698_089_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	090	0	1	01	01	H5698_090_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	090	0	1	01	01	H5698_090_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	090	0	1	01	01	H5698_090_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	090	0	1	01	01	H5698_090_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	090	0	1	01	01	H5698_090_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	090	0	1	01	01	H5698_090_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	090	0	1	01	01	H5698_090_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	090	0	1	01	01	H5698_090_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	090	0	1	01	01	H5698_090_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	090	0	1	01	01	H5698_090_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	091	0	1	01	01	H5698_091_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	091	0	1	01	01	H5698_091_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	091	0	1	01	01	H5698_091_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	091	0	1	01	01	H5698_091_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	091	0	1	01	01	H5698_091_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	091	0	1	01	01	H5698_091_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	091	0	1	01	01	H5698_091_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	091	0	1	01	01	H5698_091_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	091	0	1	01	01	H5698_091_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	091	0	1	01	01	H5698_091_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	092	0	1	01	01	H5698_092_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	092	0	1	01	01	H5698_092_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	092	0	1	01	01	H5698_092_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	092	0	1	01	01	H5698_092_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	092	0	1	01	01	H5698_092_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	092	0	1	01	01	H5698_092_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	092	0	1	01	01	H5698_092_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	092	0	1	01	01	H5698_092_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	092	0	1	01	01	H5698_092_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	092	0	1	01	01	H5698_092_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	093	0	1	01	01	H5698_093_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	093	0	1	01	01	H5698_093_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	093	0	1	01	01	H5698_093_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	093	0	1	01	01	H5698_093_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	093	0	1	01	01	H5698_093_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	093	0	1	01	01	H5698_093_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	093	0	1	01	01	H5698_093_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	093	0	1	01	01	H5698_093_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	093	0	1	01	01	H5698_093_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	093	0	1	01	01	H5698_093_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	094	0	1	01	01	H5698_094_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	094	0	1	01	01	H5698_094_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	094	0	1	01	01	H5698_094_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	094	0	1	01	01	H5698_094_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	094	0	1	01	01	H5698_094_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	094	0	1	01	01	H5698_094_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	094	0	1	01	01	H5698_094_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	094	0	1	01	01	H5698_094_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	094	0	1	01	01	H5698_094_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	094	0	1	01	01	H5698_094_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	095	0	1	01	01	H5698_095_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	095	0	1	01	01	H5698_095_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	095	0	1	01	01	H5698_095_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	095	0	1	01	01	H5698_095_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	095	0	1	01	01	H5698_095_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	095	0	1	01	01	H5698_095_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	095	0	1	01	01	H5698_095_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	095	0	1	01	01	H5698_095_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	095	0	1	01	01	H5698_095_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	095	0	1	01	01	H5698_095_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	096	0	1	01	01	H5698_096_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	096	0	1	01	01	H5698_096_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	096	0	1	01	01	H5698_096_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	096	0	1	01	01	H5698_096_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	096	0	1	01	01	H5698_096_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	096	0	1	01	01	H5698_096_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	096	0	1	01	01	H5698_096_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	096	0	1	01	01	H5698_096_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	096	0	1	01	01	H5698_096_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	096	0	1	01	01	H5698_096_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	097	0	1	01	01	H5698_097_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	097	0	1	01	01	H5698_097_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	097	0	1	01	01	H5698_097_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	097	0	1	01	01	H5698_097_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	097	0	1	01	01	H5698_097_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	097	0	1	01	01	H5698_097_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	097	0	1	01	01	H5698_097_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	097	0	1	01	01	H5698_097_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	097	0	1	01	01	H5698_097_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	097	0	1	01	01	H5698_097_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	111	0	1	02	01	H5698_111_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	111	0	1	02	01	H5698_111_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	111	0	1	02	01	H5698_111_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	111	0	1	02	01	H5698_111_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	111	0	1	02	01	H5698_111_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	111	0	1	02	01	H5698_111_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	111	0	1	02	01	H5698_111_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	111	0	1	02	01	H5698_111_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	111	0	1	02	01	H5698_111_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	111	0	1	02	01	H5698_111_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	112	0	1	02	01	H5698_112_0	6	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	112	0	1	02	01	H5698_112_0	6	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	112	0	1	02	01	H5698_112_0	6	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	112	0	1	02	01	H5698_112_0	6	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	112	0	1	02	01	H5698_112_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	112	0	1	02	01	H5698_112_0	6	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	112	0	1	02	01	H5698_112_0	6	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	112	0	1	02	01	H5698_112_0	6	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	112	0	1	02	01	H5698_112_0	6	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	112	0	1	02	01	H5698_112_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	113	0	1	02	01	H5698_113_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	113	0	1	02	01	H5698_113_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	113	0	1	02	01	H5698_113_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	113	0	1	02	01	H5698_113_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	113	0	1	02	01	H5698_113_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	113	0	1	02	01	H5698_113_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	113	0	1	02	01	H5698_113_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5698	113	0	1	02	01	H5698_113_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	113	0	1	02	01	H5698_113_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	113	0	1	02	01	H5698_113_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	114	0	1	02	01	H5698_114_0	5	2	4	1	Tier 2 - Generic	010000	1	2				Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	114	0	1	02	01	H5698_114_0	5	1	4	1	Tier 1- Preferred Generics	001000	1	2				Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	114	0	1	02	01	H5698_114_0	5	5	4	3	Tier - Specialty (Brand or Generic)	010010	1	1	2			Tier - Specialty (Brand or Generic)																							Tier - Specialty (Brand or Generic)			Tier - Specialty (Brand or Generic)																						Tier - Specialty (Brand or Generic)																					
H5698	114	0	1	02	01	H5698_114_0	5	4	4	3	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2	2			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																							Tier 4 -Non-Preferred Brand, Non-Preferred Generic			Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic																					
H5698	114	0	1	02	01	H5698_114_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5698	114	0	1	02	01	H5698_114_0	5	2	4	3	Tier 2 - Generic	010000	1	2	1		1	Tier 2 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 2 - Generic	2	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5698	114	0	1	02	01	H5698_114_0	5	1	4	3	Tier 1- Preferred Generics	001000	1	2	1		1	Tier 1- Preferred Generics	111000000010110000000	30	90								30		30								90	31	Tier 1- Preferred Generics	2	2	Tier 1- Preferred Generics																						Tier 1- Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00
H5698	114	0	1	02	01	H5698_114_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H5698	114	0	1	02	01	H5698_114_0	5	4	4	1	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	100100	1	2				Tier 4 -Non-Preferred Brand, Non-Preferred Generic	111000000010110000000	30	90								30		30								90	31	Tier 4 -Non-Preferred Brand, Non-Preferred Generic	2	2	Tier 4 -Non-Preferred Brand, Non-Preferred Generic																						Tier 4 -Non-Preferred Brand, Non-Preferred Generic	50.00	150.00								50.00		50.00	150.00								50.00
H5698	114	0	1	02	01	H5698_114_0	5	5	4	1	Tier - Specialty (Brand or Generic)	010010	1	1				Tier - Specialty (Brand or Generic)	111000000010110000000	30	90								30		30								90	31	Tier - Specialty (Brand or Generic)	2	1	Tier - Specialty (Brand or Generic)	33	33								33		33	33								33	Tier - Specialty (Brand or Generic)																					
H5700	002	0	1	01	01	H5700_002_0	19	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	69.00	207.00								69.00						138.00			207.00		69.00
H5700	002	0	1	01	01	H5700_002_0	19	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	39.00	117.00								39.00						78.00			117.00		39.00
H5700	002	0	1	01	01	H5700_002_0	19	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5700	002	0	1	01	01	H5700_002_0	19	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5700	002	0	1	01	01	H5700_002_0	19	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5700	002	0	1	01	01	H5700_002_0	19	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5700	002	0	1	01	01	H5700_002_0	19	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5700	002	0	1	01	01	H5700_002_0	19	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5700	005	0	1	01	01	H5700_005_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						0.00			15.00		5.00
H5700	005	0	1	01	01	H5700_005_0	9	3	4	3	Tier 3 - Non - Preferred Brand	100000	1	2	2			Tier 3 - Non - Preferred Brand																							Tier 3 - Non - Preferred Brand			Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand																					
H5700	005	0	1	01	01	H5700_005_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5700	005	0	1	01	01	H5700_005_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5700	005	0	1	01	01	H5700_005_0	9	4	4	1	Tier 4 - Specialty Drugs	000010	1	1				Tier 4 - Specialty Drugs	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drugs	2	4	Tier 4 - Specialty Drugs	25	25								25						25			25		25	Tier 4 - Specialty Drugs	200.00	600.00								200.00						600.00			600.00		200.00
H5700	005	0	1	01	01	H5700_005_0	9	3	4	1	Tier 3 - Non - Preferred Brand	100000	1	2				Tier 3 - Non - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non - Preferred Brand	2	2	Tier 3 - Non - Preferred Brand																						Tier 3 - Non - Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5700	005	0	1	01	01	H5700_005_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5700	005	0	1	01	01	H5700_005_0	9	4	4	3	Tier 4 - Specialty Drugs	000010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H5700	009	0	1	01	01	H5700_009_0	20	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5700	009	0	1	01	01	H5700_009_0	20	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5700	009	0	1	01	01	H5700_009_0	20	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H5700	009	0	1	01	01	H5700_009_0	20	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5700	009	0	1	01	01	H5700_009_0	20	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5700	009	0	1	01	01	H5700_009_0	20	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5700	009	0	1	01	01	H5700_009_0	20	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5700	009	0	1	01	01	H5700_009_0	20	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5700	020	0	1	01	01	H5700_020_0	18	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H5700	020	0	1	01	01	H5700_020_0	18	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5700	020	0	1	01	01	H5700_020_0	18	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5700	020	0	1	01	01	H5700_020_0	18	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5700	020	0	1	01	01	H5700_020_0	18	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5700	020	0	1	01	01	H5700_020_0	18	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5700	020	0	1	01	01	H5700_020_0	18	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5700	020	0	1	01	01	H5700_020_0	18	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5700	025	0	1	02	01	H5700_025_0	21	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H5700	025	0	1	02	01	H5700_025_0	21	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5700	025	0	1	02	01	H5700_025_0	21	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5700	025	0	1	02	01	H5700_025_0	21	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5700	025	0	1	02	01	H5700_025_0	21	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5700	025	0	1	02	01	H5700_025_0	21	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5700	025	0	1	02	01	H5700_025_0	21	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5700	025	0	1	02	01	H5700_025_0	21	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5721	004	0	1	09	04	H5721_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H5721	004	0	1	09	04	H5721_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
H5721	004	0	1	09	04	H5721_004_0	4	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
H5721	004	0	1	09	04	H5721_004_0	4	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
H5721	004	0	1	09	04	H5721_004_0	4	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5732	001	0	1	01	01	H5732_001_0	4	5	4	1	Tier 5/Nivel 5	010010	1	1				Tier 5/Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/Nivel 5	2	1	Tier 5/Nivel 5	25	25	25							25			25								25	Tier 5/Nivel 5																					
H5732	001	0	1	01	01	H5732_001_0	4	1	4	3	Tier 1/Nivel 1	010000	3	2	1		1	Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	2	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	10.00	5.00							5.00			10.00								5.00
H5732	001	0	1	01	01	H5732_001_0	4	2	4	3	Tier 2/Nivel 2	000001	3	2	2			Tier 2/Nivel 2																							Tier 2/Nivel 2			Tier 2/Nivel 2																						Tier 2/Nivel 2																					
H5732	001	0	1	01	01	H5732_001_0	4	3	4	3	Tier 3/Nivel 3	000010	3	2	2			Tier 3/Nivel 3																							Tier 3/Nivel 3			Tier 3/Nivel 3																						Tier 3/Nivel 3																					
H5732	001	0	1	01	01	H5732_001_0	4	4	4	3	Tier 4/Nivel 4	100000	1	2	2			Tier 4/Nivel 4																							Tier 4/Nivel 4			Tier 4/Nivel 4																						Tier 4/Nivel 4																					
H5732	001	0	1	01	01	H5732_001_0	4	5	4	3	Tier 5/Nivel 5	010010	1	1	2			Tier 5/Nivel 5																							Tier 5/Nivel 5			Tier 5/Nivel 5																						Tier 5/Nivel 5																					
H5732	001	0	1	01	01	H5732_001_0	4	1	4	1	Tier 1/Nivel 1	010000	3	2				Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	2	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	10.00	5.00							5.00			10.00								5.00
H5732	001	0	1	01	01	H5732_001_0	4	2	4	1	Tier 2/Nivel 2	000001	3	2				Tier 2/Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/Nivel 2	2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	20.00	40.00	20.00							20.00			40.00								20.00
H5732	001	0	1	01	01	H5732_001_0	4	3	4	1	Tier 3/Nivel 3	000010	3	2				Tier 3/Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/Nivel 3	2	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	35.00	70.00	35.00							35.00			70.00								35.00
H5732	001	0	1	01	01	H5732_001_0	4	4	4	1	Tier 4/Nivel 4	100000	1	2				Tier 4/Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/Nivel 4	2	2	Tier 4/Nivel 4																						Tier 4/Nivel 4	35.00	70.00	35.00							35.00			70.00								35.00
H5732	002	0	1	01	01	H5732_002_0	5	1	4	1	Tier 1/Nivel 1	010000	3	2				Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	2	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	3.00	6.00	3.00							3.00			6.00								3.00
H5732	002	0	1	01	01	H5732_002_0	5	2	4	1	Tier 2/Nivel 2	000001	3	2				Tier 2/Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/Nivel 2	2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	20.00	40.00	20.00							20.00			40.00								20.00
H5732	002	0	1	01	01	H5732_002_0	5	3	4	1	Tier 3/Nivel 3	000010	3	2				Tier 3/Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/Nivel 3	2	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	35.00	70.00	35.00							35.00			70.00								35.00
H5732	002	0	1	01	01	H5732_002_0	5	4	4	1	Tier 4/Nivel 4	100000	1	2				Tier 4/Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/Nivel 4	2	2	Tier 4/Nivel 4																						Tier 4/Nivel 4	35.00	70.00	35.00							35.00			70.00								35.00
H5732	002	0	1	01	01	H5732_002_0	5	5	4	3	Tier 5/Nivel 5	010010	1	1	2			Tier 5/Nivel 5																							Tier 5/Nivel 5			Tier 5/Nivel 5																						Tier 5/Nivel 5																					
H5732	002	0	1	01	01	H5732_002_0	5	1	4	3	Tier 1/Nivel 1	010000	3	2	1		1	Tier 1/Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/Nivel 1	2	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	3.00	6.00	3.00							3.00			6.00								3.00
H5732	002	0	1	01	01	H5732_002_0	5	2	4	3	Tier 2/Nivel 2	000001	3	2	1		1	Tier 2/Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/Nivel 2	2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	20.00	40.00	20.00							20.00			40.00								20.00
H5732	002	0	1	01	01	H5732_002_0	5	3	4	3	Tier 3/Nivel 3	000010	3	2	2			Tier 3/Nivel 3																							Tier 3/Nivel 3			Tier 3/Nivel 3																						Tier 3/Nivel 3																					
H5732	002	0	1	01	01	H5732_002_0	5	4	4	3	Tier 4/Nivel 4	100000	1	2	2			Tier 4/Nivel 4																							Tier 4/Nivel 4			Tier 4/Nivel 4																						Tier 4/Nivel 4																					
H5732	002	0	1	01	01	H5732_002_0	5	5	4	1	Tier 5/Nivel 5	010010	1	1				Tier 5/Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/Nivel 5	2	1	Tier 5/Nivel 5	25	25	25							25			25								25	Tier 5/Nivel 5																					
H5736	002	0	1	09	04	H5736_002_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H5736	002	0	1	09	04	H5736_002_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5736	002	0	1	09	04	H5736_002_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5736	002	0	1	09	04	H5736_002_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5736	002	0	1	09	04	H5736_002_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5736	003	0	1	09	04	H5736_003_0	5	1	4	1	Tier1 - Preferred Generic	001000	1	2				Tier1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier1 - Preferred Generic	2	2	Tier1 - Preferred Generic																						Tier1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5736	003	0	1	09	04	H5736_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5736	003	0	1	09	04	H5736_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H5736	003	0	1	09	04	H5736_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5736	003	0	1	09	04	H5736_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5736	007	0	1	09	04	H5736_007_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5736	007	0	1	09	04	H5736_007_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H5736	007	0	1	09	04	H5736_007_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5736	007	0	1	09	04	H5736_007_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5736	007	0	1	09	04	H5736_007_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5736	012	0	1	09	04	H5736_012_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5736	012	0	1	09	04	H5736_012_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H5736	012	0	1	09	04	H5736_012_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5736	012	0	1	09	04	H5736_012_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5736	012	0	1	09	04	H5736_012_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5736	014	0	1	09	04	H5736_014_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5736	014	0	1	09	04	H5736_014_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5736	014	0	1	09	04	H5736_014_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5736	014	0	1	09	04	H5736_014_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5736	014	0	1	09	04	H5736_014_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5736	014	0	1	09	04	H5736_014_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5736	014	0	1	09	04	H5736_014_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5736	014	0	1	09	04	H5736_014_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5736	014	0	1	09	04	H5736_014_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5736	014	0	1	09	04	H5736_014_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5736	017	0	1	09	04	H5736_017_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5736	017	0	1	09	04	H5736_017_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5736	017	0	1	09	04	H5736_017_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5736	017	0	1	09	04	H5736_017_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5736	017	0	1	09	04	H5736_017_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5736	017	0	1	09	04	H5736_017_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5736	017	0	1	09	04	H5736_017_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5736	017	0	1	09	04	H5736_017_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5736	017	0	1	09	04	H5736_017_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5736	017	0	1	09	04	H5736_017_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5736	024	0	1	09	04	H5736_024_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5736	024	0	1	09	04	H5736_024_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5736	024	0	1	09	04	H5736_024_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5736	024	0	1	09	04	H5736_024_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5736	024	0	1	09	04	H5736_024_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5736	025	0	1	09	04	H5736_025_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H5736	025	0	1	09	04	H5736_025_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H5736	025	0	1	09	04	H5736_025_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5736	025	0	1	09	04	H5736_025_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
H5736	025	0	1	09	04	H5736_025_0	5	1	4	1	Tier1 - Preferred Generic	001000	1	2				Tier1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier1 - Preferred Generic	2	2	Tier1 - Preferred Generic																						Tier1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5736	026	0	1	09	04	H5736_026_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5736	026	0	1	09	04	H5736_026_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5736	026	0	1	09	04	H5736_026_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5736	026	0	1	09	04	H5736_026_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5736	026	0	1	09	04	H5736_026_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5736	027	0	1	09	04	H5736_027_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5736	027	0	1	09	04	H5736_027_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5736	027	0	1	09	04	H5736_027_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5736	027	0	1	09	04	H5736_027_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5736	027	0	1	09	04	H5736_027_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5746	006	0	1	01	01	H5746_006_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H5746	006	0	1	01	01	H5746_006_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H5746	006	0	1	01	01	H5746_006_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5746	006	0	1	01	01	H5746_006_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H5746	007	0	1	01	01	H5746_007_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	007	0	1	01	01	H5746_007_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5746	007	0	1	01	01	H5746_007_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5746	007	0	1	01	01	H5746_007_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5746	007	0	1	01	01	H5746_007_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5746	007	0	1	01	01	H5746_007_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5746	007	0	1	01	01	H5746_007_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	007	0	1	01	01	H5746_007_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	35.00	70.00	52.50							35.00		35.00	70.00	52.50							35.00
H5746	011	0	1	01	01	H5746_011_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	011	0	1	01	01	H5746_011_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	35.00	70.00	52.50							35.00		35.00	70.00	52.50							35.00
H5746	011	0	1	01	01	H5746_011_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5746	011	0	1	01	01	H5746_011_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5746	011	0	1	01	01	H5746_011_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5746	011	0	1	01	01	H5746_011_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	011	0	1	01	01	H5746_011_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5746	011	0	1	01	01	H5746_011_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5746	012	0	1	02	01	H5746_012_0	7	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	012	0	1	02	01	H5746_012_0	7	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5746	012	0	1	02	01	H5746_012_0	7	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5746	012	0	1	02	01	H5746_012_0	7	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H5746	012	0	1	02	01	H5746_012_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5746	012	0	1	02	01	H5746_012_0	7	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5746	012	0	1	02	01	H5746_012_0	7	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	35.00	70.00	52.50							35.00		35.00	70.00	52.50							35.00
H5746	012	0	1	02	01	H5746_012_0	7	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5749	001	0	1	02	01	H5749_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H5749	001	0	1	02	01	H5749_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H5749	001	0	1	02	01	H5749_001_0	3	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H5749	001	0	1	02	01	H5749_001_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5750	001	0	1	02	01	H5750_001_0	6	2	4	3	Brand	000010	1	2	1		1	Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			75.00								25.00
H5750	001	0	1	02	01	H5750_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00			27.00								9.00
H5750	001	0	1	02	01	H5750_001_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
H5750	001	0	1	02	01	H5750_001_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			75.00								25.00
H5750	001	0	1	02	01	H5750_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00			27.00								9.00
H5750	001	0	1	02	01	H5750_001_0	6	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5750	003	0	1	02	01	H5750_003_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5750	003	0	1	02	01	H5750_003_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00			27.00								9.00
H5750	003	0	1	02	01	H5750_003_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
H5750	003	0	1	02	01	H5750_003_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			75.00								25.00
H5750	003	0	1	02	01	H5750_003_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.00	27.00								9.00			27.00								9.00
H5750	003	0	1	02	01	H5750_003_0	6	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5754	001	0	1	37	05	H5754_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5754	001	0	1	37	05	H5754_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5754	001	0	1	37	05	H5754_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5754	001	0	1	37	05	H5754_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5754	003	0	1	37	05	H5754_003_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5754	003	0	1	37	05	H5754_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5754	003	0	1	37	05	H5754_003_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5754	003	0	1	37	05	H5754_003_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5754	004	0	1	37	05	H5754_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5754	004	0	1	37	05	H5754_004_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5754	004	0	1	37	05	H5754_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5754	004	0	1	37	05	H5754_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5760	003	0	1	02	01	H5760_003_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5760	003	0	1	02	01	H5760_003_0	11	4	4	1	Non-Preferred Brand	100000	1	1				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	110.00								40.00											40.00
H5760	003	0	1	02	01	H5760_003_0	11	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5760	003	0	1	02	01	H5760_003_0	11	4	4	3	Non-Preferred Brand	100000	1	1	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5760	003	0	1	02	01	H5760_003_0	11	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5760	003	0	1	02	01	H5760_003_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	25.00	65.00								25.00											25.00
H5760	003	0	1	02	01	H5760_003_0	11	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00											10.00
H5760	003	0	1	02	01	H5760_003_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5760	004	0	1	02	01	H5760_004_0	8	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	10.00	20.00								10.00											10.00
H5760	004	0	1	02	01	H5760_004_0	8	1	4	1	Generic	011100	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	10.00	20.00								10.00											10.00
H5760	004	0	1	02	01	H5760_004_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5760	004	0	1	02	01	H5760_004_0	8	4	4	3	Non-Preferred Brand and Specialty	100000	1	1	2			Non-Preferred Brand and Specialty																							Non-Preferred Brand and Specialty			Non-Preferred Brand and Specialty																						Non-Preferred Brand and Specialty																					
H5760	004	0	1	02	01	H5760_004_0	8	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5760	004	0	1	02	01	H5760_004_0	8	2	4	1	Brand	000010	1	2				Brand	111000000010000000000	30	90								30											31	Brand	2	2	Brand																						Brand	20.00	50.00								20.00											20.00
H5760	004	0	1	02	01	H5760_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	110.00								40.00											40.00
H5760	004	0	1	02	01	H5760_004_0	8	4	4	1	Non-Preferred Brand and Specialty	100000	1	1				Non-Preferred Brand and Specialty	111000000010000000000	30	90								30											31	Non-Preferred Brand and Specialty	2	2	Non-Preferred Brand and Specialty																						Non-Preferred Brand and Specialty	40.00	110.00								40.00											40.00
H5760	007	0	1	02	01	H5760_007_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5760	007	0	1	02	01	H5760_007_0	6	2	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5760	007	0	1	02	01	H5760_007_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5760	007	0	1	02	01	H5760_007_0	6	4	4	3	Non-Preferred Brand	100000	1	1	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5760	007	0	1	02	01	H5760_007_0	6	4	4	1	Non-Preferred Brand	100000	1	1				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	110.00								40.00											40.00
H5760	007	0	1	02	01	H5760_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	25.00	65.00								25.00											25.00
H5760	007	0	1	02	01	H5760_007_0	6	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00											10.00
H5760	007	0	1	02	01	H5760_007_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H5774	005	0	1	01	01	H5774_005_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00									30.00	30.00	90.00								30.00
H5774	005	0	1	01	01	H5774_005_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	005	0	1	01	01	H5774_005_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	005	0	1	01	01	H5774_005_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00									15.00	15.00	45.00								15.00
H5774	005	0	1	01	01	H5774_005_0	9	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	005	0	1	01	01	H5774_005_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	005	0	1	01	01	H5774_005_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	005	0	1	01	01	H5774_005_0	9	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	006	0	1	01	01	H5774_006_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	17.00	51.00									17.00	17.00	51.00								17.00
H5774	006	0	1	01	01	H5774_006_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	3.00	9.00									3.00	3.00	9.00								3.00
H5774	006	0	1	01	01	H5774_006_0	9	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	006	0	1	01	01	H5774_006_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	006	0	1	01	01	H5774_006_0	9	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	006	0	1	01	01	H5774_006_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	006	0	1	01	01	H5774_006_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	006	0	1	01	01	H5774_006_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	008	0	1	01	01	H5774_008_0	8	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	008	0	1	01	01	H5774_008_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00									20.00	20.00	60.00								20.00
H5774	008	0	1	01	01	H5774_008_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00									35.00	35.00	105.00								35.00
H5774	008	0	1	01	01	H5774_008_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	008	0	1	01	01	H5774_008_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	008	0	1	01	01	H5774_008_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	008	0	1	01	01	H5774_008_0	8	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	008	0	1	01	01	H5774_008_0	8	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	009	0	1	01	01	H5774_009_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	009	0	1	01	01	H5774_009_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	009	0	1	01	01	H5774_009_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00									35.00	35.00	105.00								35.00
H5774	009	0	1	01	01	H5774_009_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00									20.00	20.00	60.00								20.00
H5774	009	0	1	01	01	H5774_009_0	9	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	009	0	1	01	01	H5774_009_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	009	0	1	01	01	H5774_009_0	9	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	009	0	1	01	01	H5774_009_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	014	0	1	01	01	H5774_014_0	9	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	014	0	1	01	01	H5774_014_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00									20.00	20.00	60.00								20.00
H5774	014	0	1	01	01	H5774_014_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00									35.00	35.00	105.00								35.00
H5774	014	0	1	01	01	H5774_014_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	014	0	1	01	01	H5774_014_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	014	0	1	01	01	H5774_014_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	014	0	1	01	01	H5774_014_0	9	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	014	0	1	01	01	H5774_014_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	016	0	1	01	01	H5774_016_0	10	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	016	0	1	01	01	H5774_016_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	016	0	1	01	01	H5774_016_0	10	2	4	1	Brand	000010	1	2				Brand	111000000001110000000	30	90									10	30								90	31	Brand	2	1	Brand	25	25									25	25	25								25	Brand																					
H5774	016	0	1	01	01	H5774_016_0	10	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5774	019	0	1	01	01	H5774_019_0	10	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	019	0	1	01	01	H5774_019_0	10	2	4	1	Brand	000010	1	2				Brand	111000000001110000000	30	90									10	30								90	31	Brand	2	1	Brand	25	25									25	25	25								25	Brand																					
H5774	019	0	1	01	01	H5774_019_0	10	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5774	019	0	1	01	01	H5774_019_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	020	0	1	01	01	H5774_020_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	020	0	1	01	01	H5774_020_0	10	2	4	1	Brand	000010	1	2				Brand	111000000001110000000	30	90									10	30								90	31	Brand	2	1	Brand	25	25									25	25	25								25	Brand																					
H5774	020	0	1	01	01	H5774_020_0	10	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5774	020	0	1	01	01	H5774_020_0	10	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5774	021	0	1	01	01	H5774_021_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	021	0	1	01	01	H5774_021_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5774	021	0	1	01	01	H5774_021_0	10	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5774	021	0	1	01	01	H5774_021_0	10	4	4	1	Specialty	100000	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5774	021	0	1	01	01	H5774_021_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00									35.00	35.00	105.00								35.00
H5774	021	0	1	01	01	H5774_021_0	10	4	4	3	Specialty	100000	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5774	021	0	1	01	01	H5774_021_0	10	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00	5.00	15.00								5.00
H5774	021	0	1	01	01	H5774_021_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00									20.00	20.00	60.00								20.00
H5783	002	0	1	01	01	H5783_002_0	8	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H5783	002	0	1	01	01	H5783_002_0	8	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00						7.00			15.00		5.00
H5783	002	0	1	01	01	H5783_002_0	8	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H5783	002	0	1	01	01	H5783_002_0	8	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5783	002	0	1	01	01	H5783_002_0	8	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H5783	002	0	1	01	01	H5783_002_0	8	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5783	002	0	1	01	01	H5783_002_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5783	002	0	1	01	01	H5783_002_0	8	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	3.00	9.00								3.00						0.00			9.00		3.00
H5783	006	0	1	01	01	H5783_006_0	20	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5783	006	0	1	01	01	H5783_006_0	20	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5783	006	0	1	01	01	H5783_006_0	20	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5783	006	0	1	01	01	H5783_006_0	20	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5783	006	0	1	01	01	H5783_006_0	20	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5783	006	0	1	01	01	H5783_006_0	20	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5783	006	0	1	01	01	H5783_006_0	20	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5783	006	0	1	01	01	H5783_006_0	20	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5783	009	0	1	01	01	H5783_009_0	16	2	4	3	Tier 2 - Prefered Brand	000001	1	2	2			Tier 2 - Prefered Brand																							Tier 2 - Prefered Brand			Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand																					
H5783	009	0	1	01	01	H5783_009_0	16	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H5783	009	0	1	01	01	H5783_009_0	16	4	4	3	Tier 4 - Specialty	000010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
H5783	009	0	1	01	01	H5783_009_0	16	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5783	009	0	1	01	01	H5783_009_0	16	4	4	1	Tier 4 - Specialty	000010	1	1				Tier 4 - Specialty	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty	2	4	Tier 4 - Specialty	25	25								25						25			25		25	Tier 4 - Specialty	200.00	600.00								200.00						600.00			600.00		200.00
H5783	009	0	1	01	01	H5783_009_0	16	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H5783	009	0	1	01	01	H5783_009_0	16	2	4	1	Tier 2 - Prefered Brand	000001	1	2				Tier 2 - Prefered Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Prefered Brand	2	2	Tier 2 - Prefered Brand																						Tier 2 - Prefered Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5783	009	0	1	01	01	H5783_009_0	16	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H5793	001	0	1	01	01	H5793_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5793	001	0	1	01	01	H5793_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5793	001	0	1	01	01	H5793_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5793	001	0	1	01	01	H5793_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5793	001	0	1	01	01	H5793_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5793	003	0	1	01	01	H5793_003_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5793	003	0	1	01	01	H5793_003_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5793	003	0	1	01	01	H5793_003_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5793	003	0	1	01	01	H5793_003_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5793	003	0	1	01	01	H5793_003_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5793	003	0	1	01	01	H5793_003_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5793	003	0	1	01	01	H5793_003_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5793	003	0	1	01	01	H5793_003_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5793	003	0	1	01	01	H5793_003_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5793	003	0	1	01	01	H5793_003_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5793	008	0	1	01	01	H5793_008_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H5793	008	0	1	01	01	H5793_008_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5793	008	0	1	01	01	H5793_008_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5793	008	0	1	01	01	H5793_008_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5793	008	0	1	01	01	H5793_008_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5810	001	0	1	01	01	H5810_001_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H5810	001	0	1	01	01	H5810_001_0	6	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	83.00	249.00								83.00			249.00								83.00
H5810	001	0	1	01	01	H5810_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5810	001	0	1	01	01	H5810_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00			123.00								41.00
H5810	002	0	1	01	01	H5810_002_0	7	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H5810	002	0	1	01	01	H5810_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			60.00								20.00
H5810	002	0	1	01	01	H5810_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5810	002	0	1	01	01	H5810_002_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H5811	001	0	1	01	01	H5811_001_0	6	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5811	001	0	1	01	01	H5811_001_0	6	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5811	001	0	1	01	01	H5811_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	8.00	16.00								8.00		8.00	16.00								8.00
H5811	001	0	1	01	01	H5811_001_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5811	001	0	1	01	01	H5811_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	8.00	16.00								8.00		8.00	16.00								8.00
H5811	001	0	1	01	01	H5811_001_0	6	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	34	90								34		34								90	34	Brand	2	2	Brand																						Brand	35.00	70.00								35.00		35.00	70.00								35.00
H5812	012	0	1	09	04	H5812_012_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	012	0	1	09	04	H5812_012_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	012	0	1	09	04	H5812_012_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	012	0	1	09	04	H5812_012_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	030	0	1	09	04	H5812_030_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	030	0	1	09	04	H5812_030_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	030	0	1	09	04	H5812_030_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	030	0	1	09	04	H5812_030_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	044	0	1	09	04	H5812_044_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	044	0	1	09	04	H5812_044_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	044	0	1	09	04	H5812_044_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	044	0	1	09	04	H5812_044_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	054	0	1	09	04	H5812_054_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	054	0	1	09	04	H5812_054_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	054	0	1	09	04	H5812_054_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	054	0	1	09	04	H5812_054_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	055	0	1	09	04	H5812_055_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	055	0	1	09	04	H5812_055_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	055	0	1	09	04	H5812_055_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	055	0	1	09	04	H5812_055_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	056	0	1	09	04	H5812_056_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	056	0	1	09	04	H5812_056_0	5	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	056	0	1	09	04	H5812_056_0	5	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	056	0	1	09	04	H5812_056_0	5	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	061	0	1	09	04	H5812_061_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	061	0	1	09	04	H5812_061_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	061	0	1	09	04	H5812_061_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	061	0	1	09	04	H5812_061_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	062	0	1	09	04	H5812_062_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	062	0	1	09	04	H5812_062_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	062	0	1	09	04	H5812_062_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	062	0	1	09	04	H5812_062_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5812	063	0	1	09	04	H5812_063_0	3	1	4	1	Tier 1	011100	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00
H5812	063	0	1	09	04	H5812_063_0	3	2	4	1	Tier 2	000011	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	29.00	87.00								29.00			72.50								29.00
H5812	063	0	1	09	04	H5812_063_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	2	Tier 3																						Tier 3	59.00	177.00								59.00			147.50								59.00
H5812	063	0	1	09	04	H5812_063_0	3	4	4	1	Tier 4	100000	1	1				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H5813	003	0	1	01	01	H5813_003_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
H5813	003	0	1	01	01	H5813_003_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
H5813	003	0	1	01	01	H5813_003_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5813	003	0	1	01	01	H5813_003_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5813	003	0	1	01	01	H5813_003_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5813	004	0	1	01	01	H5813_004_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
H5813	004	0	1	01	01	H5813_004_0	7	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5813	004	0	1	01	01	H5813_004_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5813	004	0	1	01	01	H5813_004_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5813	004	0	1	01	01	H5813_004_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5813	004	0	1	01	01	H5813_004_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
H5813	004	0	1	01	01	H5813_004_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
H5813	004	0	1	01	01	H5813_004_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
H5813	004	0	1	01	01	H5813_004_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5813	004	0	1	01	01	H5813_004_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
H5813	005	0	1	01	01	H5813_005_0	7	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
H5813	005	0	1	01	01	H5813_005_0	7	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H5813	005	0	1	01	01	H5813_005_0	7	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					58.00			87.00		29.00
H5813	005	0	1	01	01	H5813_005_0	7	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
H5813	005	0	1	01	01	H5813_005_0	7	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5813	006	0	1	01	01	H5813_006_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
H5813	006	0	1	01	01	H5813_006_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
H5813	006	0	1	01	01	H5813_006_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00
H5813	006	0	1	01	01	H5813_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
H5813	006	0	1	01	01	H5813_006_0	7	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
H5817	009	0	1	01	01	H5817_009_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H5817	009	0	1	01	01	H5817_009_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H5817	009	0	1	01	01	H5817_009_0	3	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	009	0	1	01	01	H5817_009_0	3	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	009	0	1	01	01	H5817_009_0	3	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5817	009	0	1	01	01	H5817_009_0	3	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	009	0	1	01	01	H5817_009_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	009	0	1	01	01	H5817_009_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	010	0	1	01	01	H5817_010_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	70.00	140.00	105.00							70.00		70.00	140.00	105.00							70.00
H5817	010	0	1	01	01	H5817_010_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H5817	010	0	1	01	01	H5817_010_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	010	0	1	01	01	H5817_010_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5817	010	0	1	01	01	H5817_010_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	010	0	1	01	01	H5817_010_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	010	0	1	01	01	H5817_010_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	010	0	1	01	01	H5817_010_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	011	0	1	01	01	H5817_011_0	7	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H5817	011	0	1	01	01	H5817_011_0	7	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	011	0	1	01	01	H5817_011_0	7	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	011	0	1	01	01	H5817_011_0	7	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5817	011	0	1	01	01	H5817_011_0	7	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	011	0	1	01	01	H5817_011_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	011	0	1	01	01	H5817_011_0	7	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	60.00	120.00	90.00							60.00		60.00	120.00	90.00							60.00
H5817	011	0	1	01	01	H5817_011_0	7	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	014	0	1	01	01	H5817_014_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	014	0	1	01	01	H5817_014_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5817	014	0	1	01	01	H5817_014_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	014	0	1	01	01	H5817_014_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	70.00	140.00	105.00							70.00		70.00	140.00	105.00							70.00
H5817	014	0	1	01	01	H5817_014_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H5817	014	0	1	01	01	H5817_014_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	014	0	1	01	01	H5817_014_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	014	0	1	01	01	H5817_014_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	015	0	1	01	01	H5817_015_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H5817	015	0	1	01	01	H5817_015_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H5817	015	0	1	01	01	H5817_015_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	015	0	1	01	01	H5817_015_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H5817	016	0	1	02	01	H5817_016_0	3	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5817	016	0	1	02	01	H5817_016_0	3	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	016	0	1	02	01	H5817_016_0	3	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	016	0	1	02	01	H5817_016_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	016	0	1	02	01	H5817_016_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	70.00	140.00	105.00							70.00		70.00	140.00	105.00							70.00
H5817	016	0	1	02	01	H5817_016_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H5817	016	0	1	02	01	H5817_016_0	3	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	016	0	1	02	01	H5817_016_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	017	0	1	02	01	H5817_017_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	70.00	140.00	105.00							70.00		70.00	140.00	105.00							70.00
H5817	017	0	1	02	01	H5817_017_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H5817	017	0	1	02	01	H5817_017_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	017	0	1	02	01	H5817_017_0	3	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5817	017	0	1	02	01	H5817_017_0	3	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5817	017	0	1	02	01	H5817_017_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5817	017	0	1	02	01	H5817_017_0	3	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5817	017	0	1	02	01	H5817_017_0	3	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5820	002	0	1	09	04	H5820_002_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H5820	002	0	1	09	04	H5820_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H5820	002	0	1	09	04	H5820_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	002	0	1	09	04	H5820_002_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	003	0	1	09	04	H5820_003_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H5820	003	0	1	09	04	H5820_003_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H5820	003	0	1	09	04	H5820_003_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	003	0	1	09	04	H5820_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	004	0	1	09	04	H5820_004_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H5820	004	0	1	09	04	H5820_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	004	0	1	09	04	H5820_004_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H5820	004	0	1	09	04	H5820_004_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	008	0	1	09	04	H5820_008_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5820	008	0	1	09	04	H5820_008_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00			75.00								25.00
H5820	008	0	1	09	04	H5820_008_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	008	0	1	09	04	H5820_008_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	009	0	1	09	04	H5820_009_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5820	009	0	1	09	04	H5820_009_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00			75.00								25.00
H5820	009	0	1	09	04	H5820_009_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	009	0	1	09	04	H5820_009_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	010	0	1	09	04	H5820_010_0	8	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5820	010	0	1	09	04	H5820_010_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00			75.00								25.00
H5820	010	0	1	09	04	H5820_010_0	8	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	010	0	1	09	04	H5820_010_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	011	0	1	09	04	H5820_011_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00
H5820	011	0	1	09	04	H5820_011_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00
H5820	011	0	1	09	04	H5820_011_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	011	0	1	09	04	H5820_011_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5820	013	0	1	09	04	H5820_013_0	7	1	4	1	Generic	010000	1	2				Generic	111100000010010000000	30	90	60							30										90	34	Generic	2	2	Generic																						Generic	0.00	0.00	0.00							0.00			0.00								0.00
H5820	013	0	1	09	04	H5820_013_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010010000000	30	90	60							30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00			75.00								25.00
H5820	013	0	1	09	04	H5820_013_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010010000000	30	90	60							30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00			180.00								60.00
H5820	013	0	1	09	04	H5820_013_0	7	4	4	1	Specialty	000010	1	1				Specialty	111100000010010000000	30	90	60							30										90	34	Specialty	2	1	Specialty	33	33	33							33			33								33	Specialty																					
H5821	001	0	1	02	01	H5821_001_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	001	0	1	02	01	H5821_001_0	5	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Preferred Brand Drugs	2	1	Preferred Brand Drugs	25	25	25								25	25	25								25	Preferred Brand Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	3	4	1	Non-Preferred Brand Drugs	100000	1	2				Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Non-Preferred Brand Drugs	2	1	Non-Preferred Brand Drugs	25	25	25								25	25	25								25	Non-Preferred Brand Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111100000001110000000	30	90	15								15	30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	3	4	3	Non-Preferred Brand Drugs	100000	1	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H5821	001	0	1	02	01	H5821_001_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	004	0	1	02	01	H5821_004_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	004	0	1	02	01	H5821_004_0	5	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	15.00	45.00	15.00								15.00	15.00	45.00								15.00
H5821	004	0	1	02	01	H5821_004_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	004	0	1	02	01	H5821_004_0	5	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111100000001110000000	30	90	15								15	30								90	31	Specialty Drugs	2	1	Specialty Drugs	20	20	20								20	20	20								20	Specialty Drugs																					
H5821	004	0	1	02	01	H5821_004_0	5	3	4	1	Non-Preferred Brand Drugs	100000	1	2				Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Non-Preferred Brand Drugs	2	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	20.00	60.00	20.00								20.00	20.00	60.00								20.00
H5821	004	0	1	02	01	H5821_004_0	5	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H5821	004	0	1	02	01	H5821_004_0	5	3	4	3	Non-Preferred Brand Drugs	100000	1	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H5821	004	0	1	02	01	H5821_004_0	5	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5821	013	0	1	02	01	H5821_013_0	5	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	15.00	45.00	15.00								15.00	15.00	45.00								15.00
H5821	013	0	1	02	01	H5821_013_0	5	3	4	1	Non-Preferred Brand Drugs	100000	1	2				Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Non-Preferred Brand Drugs	2	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	20.00	60.00	20.00								20.00	20.00	60.00								20.00
H5821	013	0	1	02	01	H5821_013_0	5	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111100000001110000000	30	90	15								15	30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																					
H5821	013	0	1	02	01	H5821_013_0	5	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	013	0	1	02	01	H5821_013_0	5	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H5821	013	0	1	02	01	H5821_013_0	5	3	4	3	Non-Preferred Brand Drugs	100000	1	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H5821	013	0	1	02	01	H5821_013_0	5	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5821	013	0	1	02	01	H5821_013_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00
H5821	015	0	1	02	01	H5821_015_0	6	3	4	1	Non-Preferred Brand Drugs	100000	1	2				Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Non-Preferred Brand Drugs	2	1	Non-Preferred Brand Drugs	25	25	25								25	25	25								25	Non-Preferred Brand Drugs																					
H5821	015	0	1	02	01	H5821_015_0	6	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111100000001110000000	30	90	15								15	30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																					
H5821	015	0	1	02	01	H5821_015_0	6	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00								0.00	0.00	0.00								0.00
H5821	015	0	1	02	01	H5821_015_0	6	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00								0.00	0.00	0.00								0.00
H5821	015	0	1	02	01	H5821_015_0	6	4	4	3	Specialty Drugs	000010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5821	015	0	1	02	01	H5821_015_0	6	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Preferred Brand Drugs	2	1	Preferred Brand Drugs	25	25	25								25	25	25								25	Preferred Brand Drugs																					
H5821	015	0	1	02	01	H5821_015_0	6	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
H5821	015	0	1	02	01	H5821_015_0	6	3	4	3	Non-Preferred Brand Drugs	100000	1	2	2			Non-Preferred Brand Drugs																							Non-Preferred Brand Drugs			Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																					
H5821	017	0	1	02	01	H5821_017_0	7	4	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	111100000001110000000	30	90	15								15	30								90	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																					
H5821	017	0	1	02	01	H5821_017_0	7	3	4	1	Non-Preferred Brand Drugs	100000	1	2				Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Non-Preferred Brand Drugs	2	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	40.00	120.00	40.00								40.00	40.00	120.00								40.00
H5821	017	0	1	02	01	H5821_017_0	7	2	4	1	Preferred Brand Drugs	000001	1	2				Preferred Brand Drugs	111100000001110000000	30	90	15								15	30								90	31	Preferred Brand Drugs	2	2	Preferred Brand Drugs																						Preferred Brand Drugs	20.00	60.00	20.00								20.00	20.00	60.00								20.00
H5821	017	0	1	02	01	H5821_017_0	7	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111100000001110000000	30	90	15								15	30								90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	5.00	15.00	5.00								5.00	5.00	15.00								5.00
H5823	002	0	1	01	01	H5823_002_0	7	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H5823	002	0	1	01	01	H5823_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H5823	002	0	1	01	01	H5823_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5823	002	0	1	01	01	H5823_002_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H5826	008	0	1	01	01	H5826_008_0	11	2	3	1	Tier 2 - Brand	000010		2				Tier 2 - Brand	111000000010010000000	34	90								34										90	34	Tier 2 - Brand	2	2	Tier 2 - Brand																						Tier 2 - Brand	50.00	150.00								50.00			150.00								50.00
H5826	008	0	1	01	01	H5826_008_0	11	3	3	1	Tier 3 - Specialty	010010		1				Tier 3 - Specialty	111000000010010000000	34	90								34										90	34	Tier 3 - Specialty	2	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																					
H5826	008	0	1	01	01	H5826_008_0	11	1	3	1	Tier 1 - Generic	010000		2				Tier 1 - Generic	111000000010010000000	34	90								34										90	34	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	11.00	33.00								11.00			33.00								11.00
H5826	009	0	1	01	01	H5826_009_0	14	2	3	1	Tier 2 - Brand	000010		2				Tier 2 - Brand	111000000010010000000	34	90								34										90	34	Tier 2 - Brand	2	2	Tier 2 - Brand																						Tier 2 - Brand	36.50	109.50								36.50			109.50								36.50
H5826	009	0	1	01	01	H5826_009_0	14	1	3	1	Tier 1 - Generic	010000		2				Tier 1 - Generic	111000000010010000000	34	90								34										90	34	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	14.00	42.00								14.00			42.00								14.00
H5826	009	0	1	01	01	H5826_009_0	14	3	3	1	Tier 3 - Specialty	010010		1				Tier 3 - Specialty	111000000010010000000	34	90								34										90	34	Tier 3 - Specialty	2	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																					
H5826	010	0	1	01	01	H5826_010_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010010000000	34	90								34										90	34	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			15.00								5.00
H5826	010	0	1	01	01	H5826_010_0	9	2	4	3	Tier 2 - Brand	000010	1	2	2			Tier 2 - Brand																							Tier 2 - Brand			Tier 2 - Brand																						Tier 2 - Brand																					
H5826	010	0	1	01	01	H5826_010_0	9	3	4	1	Tier 3 - Specialty	010010	1	1				Tier 3 - Specialty	111000000010010000000	34	90								34										90	34	Tier 3 - Specialty	2	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																					
H5826	010	0	1	01	01	H5826_010_0	9	3	4	3	Tier 3 - Specialty	010010	1	1	2			Tier 3 - Specialty																							Tier 3 - Specialty			Tier 3 - Specialty																						Tier 3 - Specialty																					
H5826	010	0	1	01	01	H5826_010_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010010000000	34	90								34										90	34	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			15.00								5.00
H5826	010	0	1	01	01	H5826_010_0	9	2	4	1	Tier 2 - Brand	000010	1	2				Tier 2 - Brand	111000000010010000000	34	90								34										90	34	Tier 2 - Brand	2	2	Tier 2 - Brand																						Tier 2 - Brand	40.00	120.00								40.00			120.00								40.00
H5832	001	0	1	01	01	H5832_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5832	001	0	1	01	01	H5832_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H5832	001	0	1	01	01	H5832_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H5832	001	0	1	01	01	H5832_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H5832	001	0	1	01	01	H5832_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5832	002	0	1	01	01	H5832_002_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5832	002	0	1	01	01	H5832_002_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
H5832	002	0	1	01	01	H5832_002_0	8	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5832	002	0	1	01	01	H5832_002_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H5832	002	0	1	01	01	H5832_002_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
H5839	001	0	1	09	04	H5839_001_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00		100.00								50.00
H5839	001	0	1	09	04	H5839_001_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		60.00								30.00
H5839	001	0	1	09	04	H5839_001_0	4	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H5839	001	0	1	09	04	H5839_001_0	4	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H5849	005	0	1	09	04	H5849_005_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
H5849	005	0	1	09	04	H5849_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00		32.00	80.00								32.00
H5849	005	0	1	09	04	H5849_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
H5849	005	0	1	09	04	H5849_005_0	5	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5849	006	0	1	09	04	H5849_006_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
H5849	006	0	1	09	04	H5849_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00		32.00	80.00								32.00
H5849	006	0	1	09	04	H5849_006_0	5	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5849	006	0	1	09	04	H5849_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
H5849	007	0	1	09	04	H5849_007_0	5	1	3	1	Generic	010000		2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
H5849	007	0	1	09	04	H5849_007_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
H5849	007	0	1	09	04	H5849_007_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00		32.00	80.00								32.00
H5849	007	0	1	09	04	H5849_007_0	5	4	3	1	Specialty	110001		1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5850	001	0	1	01	01	H5850_001_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	001	0	1	01	01	H5850_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	001	0	1	01	01	H5850_001_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5850	001	0	1	01	01	H5850_001_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	001	0	1	01	01	H5850_001_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	001	0	1	01	01	H5850_001_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	001	0	1	01	01	H5850_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	001	0	1	01	01	H5850_001_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	002	0	1	01	01	H5850_002_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	002	0	1	01	01	H5850_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H5850	002	0	1	01	01	H5850_002_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	25									25											25	Specialty Drugs																					
H5850	002	0	1	01	01	H5850_002_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00											76.00
H5850	002	0	1	01	01	H5850_002_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	002	0	1	01	01	H5850_002_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	002	0	1	01	01	H5850_002_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	002	0	1	01	01	H5850_002_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	003	0	1	01	01	H5850_003_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	003	0	1	01	01	H5850_003_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	003	0	1	01	01	H5850_003_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5850	003	0	1	01	01	H5850_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	003	0	1	01	01	H5850_003_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	003	0	1	01	01	H5850_003_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	003	0	1	01	01	H5850_003_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	003	0	1	01	01	H5850_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00		15.00	30.00								15.00
H5850	004	0	1	01	01	H5850_004_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	004	0	1	01	01	H5850_004_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00		20.00	40.00								20.00
H5850	004	0	1	01	01	H5850_004_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	004	0	1	01	01	H5850_004_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	004	0	1	01	01	H5850_004_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	004	0	1	01	01	H5850_004_0	6	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	004	0	1	01	01	H5850_004_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	004	0	1	01	01	H5850_004_0	6	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	005	0	1	01	01	H5850_005_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	005	0	1	01	01	H5850_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00		30.00	60.00								30.00
H5850	005	0	1	01	01	H5850_005_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	89.00	267.00								89.00											89.00
H5850	005	0	1	01	01	H5850_005_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	006	0	1	01	01	H5850_006_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	006	0	1	01	01	H5850_006_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	006	0	1	01	01	H5850_006_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	006	0	1	01	01	H5850_006_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	006	0	1	01	01	H5850_006_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	006	0	1	01	01	H5850_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	006	0	1	01	01	H5850_006_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	006	0	1	01	01	H5850_006_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	007	0	1	01	01	H5850_007_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	007	0	1	01	01	H5850_007_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	007	0	1	01	01	H5850_007_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00											40.00
H5850	007	0	1	01	01	H5850_007_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	007	0	1	01	01	H5850_007_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	007	0	1	01	01	H5850_007_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	007	0	1	01	01	H5850_007_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	007	0	1	01	01	H5850_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00		15.00	30.00								15.00
H5850	010	0	1	01	01	H5850_010_0	7	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00											77.00
H5850	010	0	1	01	01	H5850_010_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	010	0	1	01	01	H5850_010_0	7	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	010	0	1	01	01	H5850_010_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H5850	012	0	1	01	01	H5850_012_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	012	0	1	01	01	H5850_012_0	5	2	4	3	Preferred Brand	000001	1	2	1		1	Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	012	0	1	01	01	H5850_012_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	012	0	1	01	01	H5850_012_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	012	0	1	01	01	H5850_012_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5850	012	0	1	01	01	H5850_012_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	012	0	1	01	01	H5850_012_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	012	0	1	01	01	H5850_012_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	013	0	1	01	01	H5850_013_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	013	0	1	01	01	H5850_013_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	013	0	1	01	01	H5850_013_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5850	013	0	1	01	01	H5850_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	20.00								10.00		10.00	20.00								10.00
H5850	013	0	1	01	01	H5850_013_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	013	0	1	01	01	H5850_013_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	013	0	1	01	01	H5850_013_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	013	0	1	01	01	H5850_013_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	015	0	1	01	01	H5850_015_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	015	0	1	01	01	H5850_015_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	5.00	10.00								5.00		5.00	10.00								5.00
H5850	015	0	1	01	01	H5850_015_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	015	0	1	01	01	H5850_015_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	015	0	1	01	01	H5850_015_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	015	0	1	01	01	H5850_015_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	015	0	1	01	01	H5850_015_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	015	0	1	01	01	H5850_015_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	016	0	1	01	01	H5850_016_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	016	0	1	01	01	H5850_016_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	016	0	1	01	01	H5850_016_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	016	0	1	01	01	H5850_016_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	016	0	1	01	01	H5850_016_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	016	0	1	01	01	H5850_016_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	016	0	1	01	01	H5850_016_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00		15.00	30.00								15.00
H5850	016	0	1	01	01	H5850_016_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	017	0	1	01	01	H5850_017_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	017	0	1	01	01	H5850_017_0	5	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	017	0	1	01	01	H5850_017_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	017	0	1	01	01	H5850_017_0	5	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	017	0	1	01	01	H5850_017_0	5	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	017	0	1	01	01	H5850_017_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	017	0	1	01	01	H5850_017_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00		25.00	50.00								25.00
H5850	017	0	1	01	01	H5850_017_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	018	0	1	02	01	H5850_018_0	6	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5850	018	0	1	02	01	H5850_018_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5850	018	0	1	02	01	H5850_018_0	6	1	4	3	Preferred Generic and Select Brand	001000	3	2	1		1	Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	018	0	1	02	01	H5850_018_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	018	0	1	02	01	H5850_018_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00											50.00
H5850	018	0	1	02	01	H5850_018_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00		25.00	50.00								25.00
H5850	018	0	1	02	01	H5850_018_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5850	018	0	1	02	01	H5850_018_0	6	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	019	0	1	01	01	H5850_019_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00
H5850	019	0	1	01	01	H5850_019_0	5	1	4	1	Preferred Generic and Select Brand	001000	3	2				Preferred Generic and Select Brand	111000000010110000000	30	90								30		30								90	31	Preferred Generic and Select Brand	2	2	Preferred Generic and Select Brand																						Preferred Generic and Select Brand	0.00	0.00								0.00		0.00	0.00								0.00
H5850	019	0	1	01	01	H5850_019_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010000000000	30									30											31	Specialty Drugs	2	1	Specialty Drugs	33									33											33	Specialty Drugs																					
H5850	019	0	1	01	01	H5850_019_0	5	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00											76.00
H5854	002	0	1	01	01	H5854_002_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5854	002	0	1	01	01	H5854_002_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5854	002	0	1	01	01	H5854_002_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5854	002	0	1	01	01	H5854_002_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5854	002	0	1	01	01	H5854_002_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5854	002	0	1	01	01	H5854_002_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5854	002	0	1	01	01	H5854_002_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5854	002	0	1	01	01	H5854_002_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5854	002	0	1	01	01	H5854_002_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H5854	002	0	1	01	01	H5854_002_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5854	003	0	1	01	01	H5854_003_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H5854	003	0	1	01	01	H5854_003_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5854	003	0	1	01	01	H5854_003_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5854	003	0	1	01	01	H5854_003_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5854	003	0	1	01	01	H5854_003_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5854	003	0	1	01	01	H5854_003_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5854	003	0	1	01	01	H5854_003_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5854	003	0	1	01	01	H5854_003_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5854	003	0	1	01	01	H5854_003_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5854	003	0	1	01	01	H5854_003_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5854	005	0	1	01	01	H5854_005_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H5854	005	0	1	01	01	H5854_005_0	7	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H5854	005	0	1	01	01	H5854_005_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H5854	005	0	1	01	01	H5854_005_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H5854	005	0	1	01	01	H5854_005_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H5854	005	0	1	01	01	H5854_005_0	7	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5854	005	0	1	01	01	H5854_005_0	7	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H5854	005	0	1	01	01	H5854_005_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						150.00			225.00		75.00
H5854	005	0	1	01	01	H5854_005_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H5854	005	0	1	01	01	H5854_005_0	7	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						14.00			21.00		7.00
H5859	003	0	1	01	01	H5859_003_0	5	2	4	1	2	000010	1	2				2	111000000010110000000	34	90								34		34								90	34	2	2	2	2																						2	50.00	150.00								50.00		50.00	125.00								50.00
H5859	003	0	1	01	01	H5859_003_0	5	1	4	1	1	010000	1	2				1	111000000010110000000	34	90								34		34								90	34	1	2	2	1																						1	0.00	0.00								0.00		0.00	0.00								0.00
H5859	003	0	1	01	01	H5859_003_0	5	1	4	3	1	010000	1	2	1		1	1	111000000010110000000	34	90								34		34								90	34	1	2	2	1																						1	0.00	0.00								0.00		0.00	0.00								0.00
H5859	003	0	1	01	01	H5859_003_0	5	2	4	3	2	000010	1	2	2			2																							2			2																						2																					
H5862	001	0	1	09	04	H5862_001_0	15	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010110000000	30	90								30		30								90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5862	001	0	1	09	04	H5862_001_0	15	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00
H5862	001	0	1	09	04	H5862_001_0	15	3	4	1	Tier 3 - Non Preferred Brand	100000	1	2				Tier 3 - Non Preferred Brand	111000000010110000000	30	90								30		30								90	31	Tier 3 - Non Preferred Brand	2	2	Tier 3 - Non Preferred Brand																						Tier 3 - Non Preferred Brand	60.00	120.00								60.00		60.00	120.00								60.00
H5862	001	0	1	09	04	H5862_001_0	15	4	4	1	Tier 4 - Injectable Drugs	010011	1	2				Tier 4 - Injectable Drugs	111000000010110000000	30	90								30		30								90	31	Tier 4 - Injectable Drugs	2	1	Tier 4 - Injectable Drugs	25	25								25		25	25								25	Tier 4 - Injectable Drugs																					
H5862	001	0	1	09	04	H5862_001_0	15	5	4	1	Tier 5 - Specialty Drugs	010011	1	1				Tier 5 - Specialty Drugs	111000000010110000000	30	90								30		30								90	31	Tier 5 - Specialty Drugs	2	1	Tier 5 - Specialty Drugs	25	25								25		25	25								25	Tier 5 - Specialty Drugs																					
H5868	001	0	1	04	01	H5868_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5868	001	0	1	04	01	H5868_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5868	001	0	1	04	01	H5868_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5868	001	0	1	04	01	H5868_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5868	001	0	1	04	01	H5868_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5868	001	0	1	04	01	H5868_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5868	001	0	1	04	01	H5868_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5868	001	0	1	04	01	H5868_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5868	003	0	1	04	01	H5868_003_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5868	003	0	1	04	01	H5868_003_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5868	003	0	1	04	01	H5868_003_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5868	003	0	1	04	01	H5868_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5868	003	0	1	04	01	H5868_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5868	003	0	1	04	01	H5868_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H5868	003	0	1	04	01	H5868_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H5868	003	0	1	04	01	H5868_003_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H5883	002	1	1	01	01	H5883_002_1	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00
H5883	002	1	1	01	01	H5883_002_1	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	002	1	1	01	01	H5883_002_1	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				55.00	137.50		55.00	165.00		55.00		55.00	137.50								55.00
H5883	002	1	1	01	01	H5883_002_1	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	002	1	1	01	01	H5883_002_1	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	002	2	1	01	01	H5883_002_2	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	002	2	1	01	01	H5883_002_2	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00
H5883	002	2	1	01	01	H5883_002_2	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				55.00	137.50		55.00	165.00		55.00		55.00	137.50								55.00
H5883	002	2	1	01	01	H5883_002_2	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	002	2	1	01	01	H5883_002_2	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	002	3	1	01	01	H5883_002_3	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00
H5883	002	3	1	01	01	H5883_002_3	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	002	3	1	01	01	H5883_002_3	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				55.00	137.50		55.00	165.00		55.00		55.00	137.50								55.00
H5883	002	3	1	01	01	H5883_002_3	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	002	3	1	01	01	H5883_002_3	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	002	4	1	01	01	H5883_002_4	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	002	4	1	01	01	H5883_002_4	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00
H5883	002	4	1	01	01	H5883_002_4	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				55.00	137.50		55.00	165.00		55.00		55.00	137.50								55.00
H5883	002	4	1	01	01	H5883_002_4	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	002	4	1	01	01	H5883_002_4	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	002	7	1	01	01	H5883_002_7	8	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	002	7	1	01	01	H5883_002_7	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00
H5883	002	7	1	01	01	H5883_002_7	8	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	002	7	1	01	01	H5883_002_7	8	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				55.00	137.50		55.00	165.00		55.00		55.00	137.50								55.00
H5883	002	7	1	01	01	H5883_002_7	8	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	1	1	01	01	H5883_003_1	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5883	003	1	1	01	01	H5883_003_1	9	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5883	003	1	1	01	01	H5883_003_1	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5883	003	1	1	01	01	H5883_003_1	9	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	003	1	1	01	01	H5883_003_1	9	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H5883	003	1	1	01	01	H5883_003_1	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	003	1	1	01	01	H5883_003_1	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	125.00		50.00	150.00		50.00		50.00	125.00								50.00
H5883	003	1	1	01	01	H5883_003_1	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				25.00	62.50		25.00	75.00		25.00		25.00	62.50								25.00
H5883	003	1	1	01	01	H5883_003_1	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00
H5883	003	1	1	01	01	H5883_003_1	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	2	1	01	01	H5883_003_2	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5883	003	2	1	01	01	H5883_003_2	9	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5883	003	2	1	01	01	H5883_003_2	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5883	003	2	1	01	01	H5883_003_2	9	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	003	2	1	01	01	H5883_003_2	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	2	1	01	01	H5883_003_2	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	003	2	1	01	01	H5883_003_2	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	125.00		50.00	150.00		50.00		50.00	125.00								50.00
H5883	003	2	1	01	01	H5883_003_2	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				25.00	62.50		25.00	75.00		25.00		25.00	62.50								25.00
H5883	003	2	1	01	01	H5883_003_2	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00
H5883	003	2	1	01	01	H5883_003_2	9	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H5883	003	3	1	01	01	H5883_003_3	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00
H5883	003	3	1	01	01	H5883_003_3	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				25.00	62.50		25.00	75.00		25.00		25.00	62.50								25.00
H5883	003	3	1	01	01	H5883_003_3	9	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H5883	003	3	1	01	01	H5883_003_3	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5883	003	3	1	01	01	H5883_003_3	9	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5883	003	3	1	01	01	H5883_003_3	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5883	003	3	1	01	01	H5883_003_3	9	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	003	3	1	01	01	H5883_003_3	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	3	1	01	01	H5883_003_3	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	003	3	1	01	01	H5883_003_3	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	125.00		50.00	150.00		50.00		50.00	125.00								50.00
H5883	003	4	1	01	01	H5883_003_4	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00
H5883	003	4	1	01	01	H5883_003_4	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5883	003	4	1	01	01	H5883_003_4	9	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5883	003	4	1	01	01	H5883_003_4	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5883	003	4	1	01	01	H5883_003_4	9	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H5883	003	4	1	01	01	H5883_003_4	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	4	1	01	01	H5883_003_4	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	003	4	1	01	01	H5883_003_4	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	125.00		50.00	150.00		50.00		50.00	125.00								50.00
H5883	003	4	1	01	01	H5883_003_4	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				25.00	62.50		25.00	75.00		25.00		25.00	62.50								25.00
H5883	003	4	1	01	01	H5883_003_4	9	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	003	5	1	01	01	H5883_003_5	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				25.00	62.50		25.00	75.00		25.00		25.00	62.50								25.00
H5883	003	5	1	01	01	H5883_003_5	9	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	100011011010110000000				34	90		34	90		34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				50.00	125.00		50.00	150.00		50.00		50.00	125.00								50.00
H5883	003	5	1	01	01	H5883_003_5	9	4	4	1	Specialty	010010	1	1				Specialty	100010010010100000000				34			34			34		34									34	Specialty	2	1	Specialty				25			25			25		25									25	Specialty																					
H5883	003	5	1	01	01	H5883_003_5	9	5	4	1	Injectable	010010	1	2				Injectable	100010010010100000000				34			34			34		34									34	Injectable	2	1	Injectable				25			25			25		25									25	Injectable																					
H5883	003	5	1	01	01	H5883_003_5	9	1	4	3	Preferred Generic	011000	1	2	1		1	Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00
H5883	003	5	1	01	01	H5883_003_5	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5883	003	5	1	01	01	H5883_003_5	9	3	4	3	Non-Preferred Brand	100100	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5883	003	5	1	01	01	H5883_003_5	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5883	003	5	1	01	01	H5883_003_5	9	5	4	3	Injectable	010010	1	2	2			Injectable																							Injectable			Injectable																						Injectable																					
H5883	003	5	1	01	01	H5883_003_5	9	1	4	1	Preferred Generic	011000	1	2				Preferred Generic	100011011010110000000				34	90		34	90		34		34								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00
H5884	002	1	1	09	04	H5884_002_1	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	002	1	1	09	04	H5884_002_1	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	002	1	1	09	04	H5884_002_1	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	002	1	1	09	04	H5884_002_1	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5884	002	2	1	09	04	H5884_002_2	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5884	002	2	1	09	04	H5884_002_2	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	002	2	1	09	04	H5884_002_2	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	002	2	1	09	04	H5884_002_2	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	003	1	1	09	04	H5884_003_1	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	003	1	1	09	04	H5884_003_1	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	003	1	1	09	04	H5884_003_1	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5884	003	1	1	09	04	H5884_003_1	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	003	2	1	09	04	H5884_003_2	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	003	2	1	09	04	H5884_003_2	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	003	2	1	09	04	H5884_003_2	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	003	2	1	09	04	H5884_003_2	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5884	004	1	1	09	04	H5884_004_1	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	004	1	1	09	04	H5884_004_1	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5884	004	1	1	09	04	H5884_004_1	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	004	1	1	09	04	H5884_004_1	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	004	2	1	09	04	H5884_004_2	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H5884	004	2	1	09	04	H5884_004_2	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H5884	004	2	1	09	04	H5884_004_2	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H5884	004	2	1	09	04	H5884_004_2	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H5887	001	0	1	01	01	H5887_001_0	10	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
H5887	001	0	1	01	01	H5887_001_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5887	001	0	1	01	01	H5887_001_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5887	001	0	1	01	01	H5887_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00											15.00
H5887	006	0	1	01	01	H5887_006_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00											35.00
H5887	006	0	1	01	01	H5887_006_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5887	006	0	1	01	01	H5887_006_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00											25.00
H5887	006	0	1	01	01	H5887_006_0	10	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
H5887	007	0	1	01	01	H5887_007_0	10	4	4	3	Specialty Tier Brand	010011	1	1	2			Specialty Tier Brand																							Specialty Tier Brand			Specialty Tier Brand																						Specialty Tier Brand																					
H5887	007	0	1	01	01	H5887_007_0	10	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5887	007	0	1	01	01	H5887_007_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5887	007	0	1	01	01	H5887_007_0	10	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5887	007	0	1	01	01	H5887_007_0	10	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H5887	007	0	1	01	01	H5887_007_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
H5887	007	0	1	01	01	H5887_007_0	10	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
H5887	007	0	1	01	01	H5887_007_0	10	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
H5896	007	0	1	01	01	H5896_007_0	6	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H5896	007	0	1	01	01	H5896_007_0	6	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H5896	007	0	1	01	01	H5896_007_0	6	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H5896	007	0	1	01	01	H5896_007_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H5896	008	0	1	01	01	H5896_008_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5896	008	0	1	01	01	H5896_008_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5896	008	0	1	01	01	H5896_008_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	25.00	50.00	37.50							25.00		25.00	50.00	37.50							25.00
H5896	008	0	1	01	01	H5896_008_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H5896	009	0	1	01	01	H5896_009_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H5896	009	0	1	01	01	H5896_009_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H5896	009	0	1	01	01	H5896_009_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H5896	009	0	1	01	01	H5896_009_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H5896	009	0	1	01	01	H5896_009_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H5896	009	0	1	01	01	H5896_009_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	25.00	50.00	37.50							25.00		25.00	50.00	37.50							25.00
H5896	009	0	1	01	01	H5896_009_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5896	009	0	1	01	01	H5896_009_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5896	012	0	1	02	01	H5896_012_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H5896	012	0	1	02	01	H5896_012_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	25.00	50.00	37.50							25.00		25.00	50.00	37.50							25.00
H5896	012	0	1	02	01	H5896_012_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H5896	012	0	1	02	01	H5896_012_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H5908	003	0	1	09	04	H5908_003_0	6	1	4	1	Value Generics	010000	1	2				Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	5.00	15.00								5.00		12.50	12.50								5.00
H5908	003	0	1	09	04	H5908_003_0	6	2	4	1	Generic	010000	3	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	13.00	39.00								13.00		32.50	32.50								13.00
H5908	003	0	1	09	04	H5908_003_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
H5908	003	0	1	09	04	H5908_003_0	6	4	4	1	Non-Preferred Brand	100010	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H5908	003	0	1	09	04	H5908_003_0	6	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5908	003	0	1	09	04	H5908_003_0	6	1	4	3	Value Generics	010000	1	2	1		1	Value Generics	111000000010110000000	30	90								30		30								90	31	Value Generics	2	2	Value Generics																						Value Generics	10.00	30.00								10.00		25.00	25.00								10.00
H5908	003	0	1	09	04	H5908_003_0	6	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	26.00	78.00								26.00		65.00	65.00								26.00
H5908	003	0	1	09	04	H5908_003_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5908	003	0	1	09	04	H5908_003_0	6	4	4	3	Non-Preferred Brand	100010	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5908	003	0	1	09	04	H5908_003_0	6	5	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5918	001	0	1	37	05	H5918_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5918	001	0	1	37	05	H5918_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5918	001	0	1	37	05	H5918_001_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5918	001	0	1	37	05	H5918_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5918	003	0	1	37	05	H5918_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5918	003	0	1	37	05	H5918_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5918	003	0	1	37	05	H5918_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5918	003	0	1	37	05	H5918_003_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5918	004	0	1	37	05	H5918_004_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H5918	004	0	1	37	05	H5918_004_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H5918	004	0	1	37	05	H5918_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H5918	004	0	1	37	05	H5918_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H5926	001	0	1	01	01	H5926_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H5926	001	0	1	01	01	H5926_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	44.00	132.00								44.00			132.00								44.00
H5926	001	0	1	01	01	H5926_001_0	5	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	87.00	261.00								87.00			261.00								87.00
H5926	001	0	1	01	01	H5926_001_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H5926	002	0	1	01	01	H5926_002_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H5926	002	0	1	01	01	H5926_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H5926	002	0	1	01	01	H5926_002_0	8	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
H5926	002	0	1	01	01	H5926_002_0	8	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H5928	002	0	1	01	01	H5928_002_0	4	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	002	0	1	01	01	H5928_002_0	4	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	002	0	1	01	01	H5928_002_0	4	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	002	0	1	01	01	H5928_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	002	0	1	01	01	H5928_002_0	4	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	002	0	1	01	01	H5928_002_0	4	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	002	0	1	01	01	H5928_002_0	4	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	002	0	1	01	01	H5928_002_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	004	0	1	01	01	H5928_004_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	004	0	1	01	01	H5928_004_0	6	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	004	0	1	01	01	H5928_004_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	004	0	1	01	01	H5928_004_0	6	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	004	0	1	01	01	H5928_004_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	004	0	1	01	01	H5928_004_0	6	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	004	0	1	01	01	H5928_004_0	6	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	004	0	1	01	01	H5928_004_0	6	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	006	0	1	01	01	H5928_006_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	006	0	1	01	01	H5928_006_0	5	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	006	0	1	01	01	H5928_006_0	5	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	006	0	1	01	01	H5928_006_0	5	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	006	0	1	01	01	H5928_006_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	006	0	1	01	01	H5928_006_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	006	0	1	01	01	H5928_006_0	5	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	006	0	1	01	01	H5928_006_0	5	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	008	0	1	01	01	H5928_008_0	6	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	008	0	1	01	01	H5928_008_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	008	0	1	01	01	H5928_008_0	6	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	008	0	1	01	01	H5928_008_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	008	0	1	01	01	H5928_008_0	6	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	008	0	1	01	01	H5928_008_0	6	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	008	0	1	01	01	H5928_008_0	6	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	008	0	1	01	01	H5928_008_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	010	0	1	01	01	H5928_010_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	010	0	1	01	01	H5928_010_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	010	0	1	01	01	H5928_010_0	5	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	010	0	1	01	01	H5928_010_0	5	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	010	0	1	01	01	H5928_010_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	010	0	1	01	01	H5928_010_0	5	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	010	0	1	01	01	H5928_010_0	5	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	010	0	1	01	01	H5928_010_0	5	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	011	0	1	01	01	H5928_011_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5928	011	0	1	01	01	H5928_011_0	5	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	011	0	1	01	01	H5928_011_0	5	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	011	0	1	01	01	H5928_011_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	011	0	1	01	01	H5928_011_0	5	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	011	0	1	01	01	H5928_011_0	5	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	011	0	1	01	01	H5928_011_0	5	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	011	0	1	01	01	H5928_011_0	5	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	012	0	1	01	01	H5928_012_0	4	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	012	0	1	01	01	H5928_012_0	4	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	50.00								25.00			50.00								25.00
H5928	012	0	1	01	01	H5928_012_0	4	3	4	1	Other Non-Preferred	100100	1	2				Other Non-Preferred	111000000010010000000	30	90								30										90	31	Other Non-Preferred	2	2	Other Non-Preferred																						Other Non-Preferred	40.00	80.00								40.00			80.00								40.00
H5928	012	0	1	01	01	H5928_012_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	20	20								20			20								20	Specialty																					
H5928	012	0	1	01	01	H5928_012_0	4	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00
H5928	012	0	1	01	01	H5928_012_0	4	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H5928	012	0	1	01	01	H5928_012_0	4	3	4	3	Other Non-Preferred	100100	1	2	2			Other Non-Preferred																							Other Non-Preferred			Other Non-Preferred																						Other Non-Preferred																					
H5928	012	0	1	01	01	H5928_012_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5932	001	0	1	01	01	H5932_001_0	4	3	4	1	Tier 3	000010	1	2				Tier 3	110000000010000000000	30									30											31	Tier 3	2	2	Tier 3																						Tier 3	98.00									98.00											98.00
H5932	001	0	1	01	01	H5932_001_0	4	2	4	1	Tier 2	000010	1	2				Tier 2	110000000010000000000	30									30											31	Tier 2	2	2	Tier 2																						Tier 2	47.00									47.00											47.00
H5932	001	0	1	01	01	H5932_001_0	4	1	4	1	Tier 1	010000	1	2				Tier 1	110000000010000000000	30									30											31	Tier 1	2	2	Tier 1																						Tier 1	0.00									0.00											0.00
H5932	001	0	1	01	01	H5932_001_0	4	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H5938	001	0	1	01	01	H5938_001_0	7	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	110000000010000000000	30									30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00									50.00											50.00
H5938	001	0	1	01	01	H5938_001_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	110000000010000000000	30									30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00									30.00											30.00
H5938	001	0	1	01	01	H5938_001_0	7	1	3	1	Generic	010000		2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	15.00									15.00											15.00
H5938	001	0	1	01	01	H5938_001_0	7	4	3	1	Specialty Brand/Generic	010010		1				Specialty Brand/Generic	110000000010000000000	30									30											31	Specialty Brand/Generic	2	1	Specialty Brand/Generic	10									10											10	Specialty Brand/Generic																					
H5938	006	0	1	01	01	H5938_006_0	7	1	4	1	Generic	010000	1	2				Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	15.00									15.00											15.00
H5938	006	0	1	01	01	H5938_006_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	110000000010000000000	30									30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00									30.00											30.00
H5938	006	0	1	01	01	H5938_006_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	110000000010000000000	30									30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00									50.00											50.00
H5938	006	0	1	01	01	H5938_006_0	7	4	4	1	Specialty Brand/Generic	010010	1	1				Specialty Brand/Generic	110000000010000000000	30									30											31	Specialty Brand/Generic	2	1	Specialty Brand/Generic	10									10											10	Specialty Brand/Generic																					
H5938	006	0	1	01	01	H5938_006_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	110000000010000000000	30									30											31	Generic	2	2	Generic																						Generic	15.00									15.00											15.00
H5938	006	0	1	01	01	H5938_006_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5938	006	0	1	01	01	H5938_006_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H5938	006	0	1	01	01	H5938_006_0	7	4	4	3	Specialty Brand/Generic	010010	1	1	2			Specialty Brand/Generic																							Specialty Brand/Generic			Specialty Brand/Generic																						Specialty Brand/Generic																					
H5943	001	0	1	39	05	H5943_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	6.00	18.00								6.00			12.00								6.00
H5943	001	0	1	39	05	H5943_001_0	6	4	4	1	Specialty	010001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H5943	001	0	1	39	05	H5943_001_0	6	3	4	1	Additional Brand	000010	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	55.00	165.00								55.00			110.00								55.00
H5943	001	0	1	39	05	H5943_001_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H5948	001	0	1	01	01	H5948_001_0	4	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5948	001	0	1	01	01	H5948_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	70.00									35.00	35.00	70.00								35.00
H5948	001	0	1	01	01	H5948_001_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non Preferred Brand	2	1	Non Preferred Brand	33	33									33	33	33								33	Non Preferred Brand																					
H5948	001	0	1	01	01	H5948_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	33	33									33	33	33								33	Specialty																					
H5948	001	0	1	01	01	H5948_001_0	4	5	4	1	Lifestyle Enhancement	010010	2	2				Lifestyle Enhancement	110000000001001000000	30										10		4								31	Lifestyle Enhancement	2	2	Lifestyle Enhancement																						Lifestyle Enhancement	0.00										0.00			0.00							0.00
H5948	001	0	1	01	01	H5948_001_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5948	001	0	1	01	01	H5948_001_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5948	001	0	1	01	01	H5948_001_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H5948	001	0	1	01	01	H5948_001_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5948	001	0	1	01	01	H5948_001_0	4	5	4	3	Lifestyle Enhancement	010010	2	2	1		1	Lifestyle Enhancement	110000000001001000000	30										10		4								31	Lifestyle Enhancement	2	2	Lifestyle Enhancement																						Lifestyle Enhancement	0.00										0.00			0.00							0.00
H5948	002	0	1	01	01	H5948_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	25	25									25	25	25								25	Specialty																					
H5948	002	0	1	01	01	H5948_002_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	94.00	282.00									94.00	94.00	282.00								94.00
H5948	002	0	1	01	01	H5948_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00									45.00	45.00	135.00								45.00
H5948	002	0	1	01	01	H5948_002_0	4	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5948	002	0	1	01	01	H5948_002_0	4	5	4	1	Lifestyle Enhancement	010010	2	2				Lifestyle Enhancement	110000000001001000000	30										10		4								31	Lifestyle Enhancement	2	2	Lifestyle Enhancement																						Lifestyle Enhancement	0.00										0.00			0.00							0.00
H5948	003	0	1	01	01	H5948_003_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5948	003	0	1	01	01	H5948_003_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5948	003	0	1	01	01	H5948_003_0	4	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H5948	003	0	1	01	01	H5948_003_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5948	003	0	1	01	01	H5948_003_0	4	5	4	1	Lifestyle Enhancement	010010	2	2				Lifestyle Enhancement	110000000001001000000	30										10		4								31	Lifestyle Enhancement	2	2	Lifestyle Enhancement																						Lifestyle Enhancement	0.00										0.00			0.00							0.00
H5948	003	0	1	01	01	H5948_003_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000001110000000	30	90									10	30								90	31	Specialty	2	1	Specialty	33	33									33	33	33								33	Specialty																					
H5948	003	0	1	01	01	H5948_003_0	4	5	4	3	Lifestyle Enhancement	010010	2	2	1		1	Lifestyle Enhancement	110000000001001000000	30										10		4								31	Lifestyle Enhancement	2	2	Lifestyle Enhancement																						Lifestyle Enhancement	0.00										0.00			0.00							0.00
H5948	003	0	1	01	01	H5948_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001110000000	30	90									10	30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	70.00									35.00	35.00	70.00								35.00
H5948	003	0	1	01	01	H5948_003_0	4	1	4	1	Generic	010000	1	2				Generic	111000000001110000000	30	90									10	30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00
H5948	003	0	1	01	01	H5948_003_0	4	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000001110000000	30	90									10	30								90	31	Non Preferred Brand	2	1	Non Preferred Brand	33	33									33	33	33								33	Non Preferred Brand																					
H5950	001	0	1	01	01	H5950_001_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H5950	001	0	1	01	01	H5950_001_0	5	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5950	001	0	1	01	01	H5950_001_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
H5950	001	0	1	01	01	H5950_001_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
H5950	001	0	1	01	01	H5950_001_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
H5950	002	0	1	01	01	H5950_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H5950	002	0	1	01	01	H5950_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H5950	002	0	1	01	01	H5950_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
H5950	002	0	1	01	01	H5950_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H5950	002	0	1	01	01	H5950_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H5950	003	0	1	01	01	H5950_003_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H5950	003	0	1	01	01	H5950_003_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H5950	003	0	1	01	01	H5950_003_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H5950	003	0	1	01	01	H5950_003_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H5950	003	0	1	01	01	H5950_003_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H5950	003	0	1	01	01	H5950_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5950	003	0	1	01	01	H5950_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H5950	003	0	1	01	01	H5950_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H5950	003	0	1	01	01	H5950_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H5950	003	0	1	01	01	H5950_003_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H5952	001	0	1	09	04	H5952_001_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
H5952	001	0	1	09	04	H5952_001_0	8	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
H5952	001	0	1	09	04	H5952_001_0	8	3	3	1	Non Preferred Generic/Non Preferred Brand	100100		2				Non Preferred Generic/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Generic/Non Preferred Brand	2	2	Non Preferred Generic/Non Preferred Brand																						Non Preferred Generic/Non Preferred Brand	71.00	213.00								71.00			213.00								71.00
H5952	001	0	1	09	04	H5952_001_0	8	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H5969	001	0	1	01	01	H5969_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H5969	001	0	1	01	01	H5969_001_0	6	3	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H5969	001	0	1	01	01	H5969_001_0	6	2	4	1	Brand	100011	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	1	Brand	30	30								30		30	30								30	Brand																					
H5980	006	0	1	01	01	H5980_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H5980	006	0	1	01	01	H5980_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H5980	006	0	1	01	01	H5980_006_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5980	007	0	1	01	01	H5980_007_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
H5980	007	0	1	01	01	H5980_007_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H5980	007	0	1	01	01	H5980_007_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H5985	001	0	1	01	01	H5985_001_0	5	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H5985	001	0	1	01	01	H5985_001_0	5	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5985	001	0	1	01	01	H5985_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5985	001	0	1	01	01	H5985_001_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00
H5985	001	0	1	01	01	H5985_001_0	5	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	20	20								20		20	20								20	Specialty																					
H5985	001	0	1	01	01	H5985_001_0	5	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	55.00	165.00								55.00		55.00	165.00								55.00
H5985	001	0	1	01	01	H5985_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	45.00								15.00
H5985	001	0	1	01	01	H5985_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	30.00								10.00
H5989	003	0	1	01	01	H5989_003_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5989	003	0	1	01	01	H5989_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
H5989	003	0	1	01	01	H5989_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H5989	003	0	1	01	01	H5989_003_0	6	4	4	1	Specialty	111100	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5989	004	0	1	01	01	H5989_004_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	1	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H5989	004	0	1	01	01	H5989_004_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
H5989	004	0	1	01	01	H5989_004_0	9	4	4	1	Specialty	111100	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H5989	004	0	1	01	01	H5989_004_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
H5992	001	0	1	01	01	H5992_001_0	8	1	4	1	enhanced alternative-generic	010000	1	2				enhanced alternative-generic	111000000010110000000	34	93								34		34								93	34	enhanced alternative-generic	2	2	enhanced alternative-generic																						enhanced alternative-generic	0.00	0.00								0.00		0.00	0.00								0.00
H5992	001	0	1	01	01	H5992_001_0	8	2	4	1	enhanced alternative-brand	000010	1	2				enhanced alternative-brand	111000000010110000000	34	93								34		34								93	34	enhanced alternative-brand	2	2	enhanced alternative-brand																						enhanced alternative-brand	45.00	135.00								45.00		45.00	90.00								45.00
H5992	002	0	1	01	01	H5992_002_0	7	1	4	1	enhanced alternative-generic	010000	1	2				enhanced alternative-generic	111000000010110000000	34	93								34		34								93	34	enhanced alternative-generic	2	2	enhanced alternative-generic																						enhanced alternative-generic	0.00	0.00								0.00		0.00	0.00								0.00
H5992	002	0	1	01	01	H5992_002_0	7	2	4	1	enhanced alternative-brand	000010	1	2				enhanced alternative-brand	111000000010110000000	34	93								34		34								93	34	enhanced alternative-brand	2	2	enhanced alternative-brand																						enhanced alternative-brand	45.00	135.00								45.00		45.00	90.00								45.00
H5992	003	0	1	01	01	H5992_003_0	5	1	4	1	enhanced alternative-generic	010000	1	2				enhanced alternative-generic	111000000010110000000	34	93								34		34								93	34	enhanced alternative-generic	2	2	enhanced alternative-generic																						enhanced alternative-generic	0.00	0.00								0.00		0.00	0.00								0.00
H5992	003	0	1	01	01	H5992_003_0	5	2	4	1	enhanced alternative-brand	000010	1	2				enhanced alternative-brand	111000000010110000000	34	93								34		34								93	34	enhanced alternative-brand	2	2	enhanced alternative-brand																						enhanced alternative-brand	45.00	135.00								45.00		45.00	90.00								45.00
H5995	002	0	1	01	01	H5995_002_0	4	1	4	1	Tier 1 - Generics	010000	1	2				Tier 1 - Generics	111000000010110000000	30	90								30		30								90	31	Tier 1 - Generics	2	2	Tier 1 - Generics																						Tier 1 - Generics	5.00	15.00								5.00		5.00	15.00								5.00
H5995	002	0	1	01	01	H5995_002_0	4	3	4	1	Tier 3 - Specialty	010010	1	1				Tier 3 - Specialty	111000000010110000000	30	90								30		30								90	31	Tier 3 - Specialty	2	1	Tier 3 - Specialty	25	25								25		25	25								25	Tier 3 - Specialty																					
H5995	002	0	1	01	01	H5995_002_0	4	2	4	1	Tier 2 - Brands	000010	1	2				Tier 2 - Brands	111000000010110000000	30	90								30		30								90	31	Tier 2 - Brands	2	2	Tier 2 - Brands																						Tier 2 - Brands	20.00	60.00								20.00		20.00	60.00								20.00
H5996	011	0	1	09	04	H5996_011_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	011	0	1	09	04	H5996_011_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	011	0	1	09	04	H5996_011_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	011	0	1	09	04	H5996_011_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	011	0	1	09	04	H5996_011_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	012	0	1	09	04	H5996_012_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	012	0	1	09	04	H5996_012_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	012	0	1	09	04	H5996_012_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	012	0	1	09	04	H5996_012_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	012	0	1	09	04	H5996_012_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	013	0	1	09	04	H5996_013_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	013	0	1	09	04	H5996_013_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	89.00	267.00	178.00							89.00						222.50	178.00	89.00	267.00	178.00	89.00
H5996	013	0	1	09	04	H5996_013_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H5996	013	0	1	09	04	H5996_013_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H5996	013	0	1	09	04	H5996_013_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	015	0	1	09	04	H5996_015_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	015	0	1	09	04	H5996_015_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	015	0	1	09	04	H5996_015_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	015	0	1	09	04	H5996_015_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	015	0	1	09	04	H5996_015_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	018	0	1	09	04	H5996_018_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	018	0	1	09	04	H5996_018_0	9	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	018	0	1	09	04	H5996_018_0	9	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	018	0	1	09	04	H5996_018_0	9	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	018	0	1	09	04	H5996_018_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	019	0	1	09	04	H5996_019_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H5996	019	0	1	09	04	H5996_019_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	019	0	1	09	04	H5996_019_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H5996	019	0	1	09	04	H5996_019_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	89.00	267.00	178.00							89.00						222.50	178.00	89.00	267.00	178.00	89.00
H5996	019	0	1	09	04	H5996_019_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	020	0	1	09	04	H5996_020_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	020	0	1	09	04	H5996_020_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	020	0	1	09	04	H5996_020_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	8.00	4.00	12.00	8.00	4.00
H5996	020	0	1	09	04	H5996_020_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	89.00	267.00	178.00							89.00						222.50	178.00	89.00	267.00	178.00	89.00
H5996	020	0	1	09	04	H5996_020_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
H5996	026	0	1	09	04	H5996_026_0	11	5	4	1	Speciality	010010	1	1				Speciality	110000000010000100100	30									30				30			30				34	Speciality	2	1	Speciality	33									33					33			33			33	Speciality																					
H5996	026	0	1	09	04	H5996_026_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	026	0	1	09	04	H5996_026_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	026	0	1	09	04	H5996_026_0	11	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	026	0	1	09	04	H5996_026_0	11	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	027	0	1	09	04	H5996_027_0	9	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	027	0	1	09	04	H5996_027_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	027	0	1	09	04	H5996_027_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	027	0	1	09	04	H5996_027_0	9	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	027	0	1	09	04	H5996_027_0	9	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	029	0	1	09	04	H5996_029_0	9	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	029	0	1	09	04	H5996_029_0	9	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	029	0	1	09	04	H5996_029_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	029	0	1	09	04	H5996_029_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	029	0	1	09	04	H5996_029_0	9	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	031	0	1	09	04	H5996_031_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	031	0	1	09	04	H5996_031_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						8.00	4.00	4.00	12.00	8.00	4.00
H5996	031	0	1	09	04	H5996_031_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	031	0	1	09	04	H5996_031_0	6	3	4	1	Non Preferred Brand	100100	1	2				Non Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non Preferred Brand	1	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00						175.00	140.00	70.00	210.00	140.00	70.00
H5996	031	0	1	09	04	H5996_031_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	035	0	1	09	04	H5996_035_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	035	0	1	09	04	H5996_035_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	035	0	1	09	04	H5996_035_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	035	0	1	09	04	H5996_035_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	035	0	1	09	04	H5996_035_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	036	0	1	09	04	H5996_036_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	036	0	1	09	04	H5996_036_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	036	0	1	09	04	H5996_036_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	036	0	1	09	04	H5996_036_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	036	0	1	09	04	H5996_036_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	037	0	1	09	04	H5996_037_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	037	0	1	09	04	H5996_037_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	037	0	1	09	04	H5996_037_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	037	0	1	09	04	H5996_037_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	037	0	1	09	04	H5996_037_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	041	0	1	09	04	H5996_041_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	041	0	1	09	04	H5996_041_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	041	0	1	09	04	H5996_041_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	041	0	1	09	04	H5996_041_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	041	0	1	09	04	H5996_041_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	042	0	1	09	04	H5996_042_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	042	0	1	09	04	H5996_042_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	042	0	1	09	04	H5996_042_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	042	0	1	09	04	H5996_042_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	042	0	1	09	04	H5996_042_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	043	0	1	09	04	H5996_043_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	043	0	1	09	04	H5996_043_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	1	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	043	0	1	09	04	H5996_043_0	6	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	043	0	1	09	04	H5996_043_0	6	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	043	0	1	09	04	H5996_043_0	6	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	049	0	1	09	04	H5996_049_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	049	0	1	09	04	H5996_049_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	049	0	1	09	04	H5996_049_0	7	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	049	0	1	09	04	H5996_049_0	7	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	049	0	1	09	04	H5996_049_0	7	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	050	0	1	09	04	H5996_050_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	050	0	1	09	04	H5996_050_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	050	0	1	09	04	H5996_050_0	7	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	050	0	1	09	04	H5996_050_0	7	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	050	0	1	09	04	H5996_050_0	7	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	051	0	1	09	04	H5996_051_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00						70.00	70.00	35.00	105.00	70.00	35.00
H5996	051	0	1	09	04	H5996_051_0	7	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00	160.00							80.00						200.00	160.00	80.00	240.00	160.00	80.00
H5996	051	0	1	09	04	H5996_051_0	7	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	051	0	1	09	04	H5996_051_0	7	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5996	051	0	1	09	04	H5996_051_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00	14.00							7.00						14.00	14.00	7.00	21.00	14.00	7.00
H5996	069	0	1	09	04	H5996_069_0	9	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
H5996	069	0	1	09	04	H5996_069_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
H5996	069	0	1	09	04	H5996_069_0	9	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred	1	2	Non-Preferred																						Non-Preferred	74.00	222.00	148.00							74.00						185.00	148.00	74.00	222.00	148.00	74.00
H5996	069	0	1	09	04	H5996_069_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
H5996	069	0	1	09	04	H5996_069_0	9	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H5998	001	0	1	01	01	H5998_001_0	8	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H5998	001	0	1	01	01	H5998_001_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H5998	001	0	1	01	01	H5998_001_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H5998	001	0	1	01	01	H5998_001_0	8	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5998	002	0	1	01	01	H5998_002_0	6	4	4	3	Non-Preferred	100100	1	2	2			Non-Preferred																							Non-Preferred			Non-Preferred																						Non-Preferred																					
H5998	002	0	1	01	01	H5998_002_0	6	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H5998	002	0	1	01	01	H5998_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H5998	002	0	1	01	01	H5998_002_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H5998	002	0	1	01	01	H5998_002_0	6	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010010000000	30	90								30										90	31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	50.00	150.00								50.00			150.00								50.00
H5998	002	0	1	01	01	H5998_002_0	6	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H5998	002	0	1	01	01	H5998_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H5998	002	0	1	01	01	H5998_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00
H6120	002	0	1	01	01	H6120_002_0	6	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H6120	002	0	1	01	01	H6120_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H6120	002	0	1	01	01	H6120_002_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H6120	002	0	1	01	01	H6120_002_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H6120	002	0	1	01	01	H6120_002_0	6	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H6120	002	0	1	01	01	H6120_002_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H6120	002	0	1	01	01	H6120_002_0	6	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H6120	002	0	1	01	01	H6120_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H6120	003	0	1	01	01	H6120_003_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H6120	003	0	1	01	01	H6120_003_0	6	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H6120	003	0	1	01	01	H6120_003_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H6120	003	0	1	01	01	H6120_003_0	6	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H6120	003	0	1	01	01	H6120_003_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H6120	003	0	1	01	01	H6120_003_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H6120	003	0	1	01	01	H6120_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H6120	003	0	1	01	01	H6120_003_0	6	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H6145	001	0	1	04	01	H6145_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001010000000	31	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00									65.00		130.00								65.00
H6145	001	0	1	04	01	H6145_001_0	6	1	4	1	Generic	011000	1	2				Generic	111000000001010000000	31	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		10.00								5.00
H6145	001	0	1	04	01	H6145_001_0	6	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	111000000001010000000	31	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00									40.00		80.00								40.00
H6145	001	0	1	04	01	H6145_001_0	6	4	4	1	Specialty	100011	1	1				Specialty	110000000001000000000	31										10										31	Specialty	2	1	Specialty	25										25										25	Specialty																					
H6178	001	0	1	01	01	H6178_001_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	34	90								34										90	34	Tier 2	2	2	Tier 2																						Tier 2	40.50	121.50								40.50			121.50								40.50
H6178	001	0	1	01	01	H6178_001_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	34	90								34										90	34	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H6178	001	0	1	01	01	H6178_001_0	6	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010010000000	34	90								34										90	34	Tier 3	2	1	Tier 3	25	25								25			25								25	Tier 3																					
H6178	001	0	1	01	01	H6178_001_0	6	4	4	1	Tier 4	100000	1	2				Tier 4	111000000010010000000	34	90								34										90	34	Tier 4	2	2	Tier 4																						Tier 4	81.00	243.00								81.00			243.00								81.00
H6181	007	0	1	01	01	H6181_007_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H6181	007	0	1	01	01	H6181_007_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H6181	007	0	1	01	01	H6181_007_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H6181	007	0	1	01	01	H6181_007_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H6181	008	0	1	01	01	H6181_008_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6181	008	0	1	01	01	H6181_008_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H6181	008	0	1	01	01	H6181_008_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H6181	008	0	1	01	01	H6181_008_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H6181	008	0	1	01	01	H6181_008_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6181	008	0	1	01	01	H6181_008_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H6181	008	0	1	01	01	H6181_008_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H6181	008	0	1	01	01	H6181_008_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H6181	009	0	1	01	01	H6181_009_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H6181	009	0	1	01	01	H6181_009_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H6181	009	0	1	01	01	H6181_009_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6181	009	0	1	01	01	H6181_009_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H6181	009	0	1	01	01	H6181_009_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H6181	009	0	1	01	01	H6181_009_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H6181	009	0	1	01	01	H6181_009_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6181	009	0	1	01	01	H6181_009_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H6181	013	0	1	02	01	H6181_013_0	3	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H6181	013	0	1	02	01	H6181_013_0	3	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H6181	013	0	1	02	01	H6181_013_0	3	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H6181	013	0	1	02	01	H6181_013_0	3	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6181	013	0	1	02	01	H6181_013_0	3	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H6181	013	0	1	02	01	H6181_013_0	3	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H6181	013	0	1	02	01	H6181_013_0	3	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H6181	013	0	1	02	01	H6181_013_0	3	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H6184	001	0	1	01	01	H6184_001_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H6184	001	0	1	01	01	H6184_001_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H6184	001	0	1	01	01	H6184_001_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H6184	001	0	1	01	01	H6184_001_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H6184	001	0	1	01	01	H6184_001_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H6184	001	0	1	01	01	H6184_001_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H6184	001	0	1	01	01	H6184_001_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H6184	001	0	1	01	01	H6184_001_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H6184	001	0	1	01	01	H6184_001_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H6184	001	0	1	01	01	H6184_001_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H6228	001	0	1	37	05	H6228_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H6228	001	0	1	37	05	H6228_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H6228	001	0	1	37	05	H6228_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H6228	001	0	1	37	05	H6228_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H6228	003	0	1	37	05	H6228_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H6228	003	0	1	37	05	H6228_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H6228	003	0	1	37	05	H6228_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H6228	003	0	1	37	05	H6228_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H6328	001	0	1	04	01	H6328_001_0	10	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6328	001	0	1	04	01	H6328_001_0	10	3	4	3	Non-Preferred Drugs	100100	1	2	2			Non-Preferred Drugs																							Non-Preferred Drugs			Non-Preferred Drugs																						Non-Preferred Drugs																					
H6328	001	0	1	04	01	H6328_001_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H6328	001	0	1	04	01	H6328_001_0	10	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00	0.00		4.00	12.00		4.00		4.00	12.00								4.00
H6328	001	0	1	04	01	H6328_001_0	10	4	4	1	Specialty	010010	1	1				Specialty	100011011010110000000				30	90		30	90		30		30								90	31	Specialty	2	1	Specialty				25	25		25	25		25		25	25								25	Specialty																					
H6328	001	0	1	04	01	H6328_001_0	10	3	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	100011011010110000000				30	90		30	90		30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs				55.00	165.00		55.00	165.00		55.00		55.00	165.00								55.00
H6328	001	0	1	04	01	H6328_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	90.00		30.00	90.00		30.00		30.00	90.00								30.00
H6328	001	0	1	04	01	H6328_001_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00	0.00		4.00	12.00		4.00		4.00	12.00								4.00
H6328	002	0	1	04	01	H6328_002_0	8	3	4	3	Non-Preferred Drugs	100100	1	2	2			Non-Preferred Drugs																							Non-Preferred Drugs			Non-Preferred Drugs																						Non-Preferred Drugs																					
H6328	002	0	1	04	01	H6328_002_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6328	002	0	1	04	01	H6328_002_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H6328	002	0	1	04	01	H6328_002_0	8	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00		5.00		5.00	15.00								5.00
H6328	002	0	1	04	01	H6328_002_0	8	4	4	1	Specialty	010010	1	1				Specialty	100011011010110000000				30	90		30	90		30		30								90	31	Specialty	2	1	Specialty				33	33		33	33		33		33	33								33	Specialty																					
H6328	002	0	1	04	01	H6328_002_0	8	3	4	1	Non-Preferred Drugs	100100	1	2				Non-Preferred Drugs	100011011010110000000				30	90		30	90		30		30								90	31	Non-Preferred Drugs	2	2	Non-Preferred Drugs																						Non-Preferred Drugs				60.00	180.00		60.00	180.00		60.00		60.00	180.00								60.00
H6328	002	0	1	04	01	H6328_002_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				33.00	99.00		33.00	99.00		33.00		33.00	99.00								33.00
H6328	002	0	1	04	01	H6328_002_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	100011011010110000000				30	90		30	90		30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00		5.00		5.00	15.00								5.00
H6360	001	0	1	18	06	H6360_001_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H6360	001	0	1	18	06	H6360_001_0	7	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H6360	001	0	1	18	06	H6360_001_0	7	2	4	1	Brand-Name	000010	1	2				Brand-Name	111000000010110000000	31	90								31		31								90	31	Brand-Name	2	2	Brand-Name																						Brand-Name	40.00	120.00								40.00		40.00	80.00								40.00
H6360	001	0	1	18	06	H6360_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H6360	001	0	1	18	06	H6360_001_0	7	2	4	3	Brand-Name	000010	1	2	2			Brand-Name																							Brand-Name			Brand-Name																						Brand-Name																					
H6360	001	0	1	18	06	H6360_001_0	7	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6360	002	0	1	18	06	H6360_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H6360	002	0	1	18	06	H6360_002_0	6	2	4	1	Brand-Name	000010	1	2				Brand-Name	111000000010110000000	31	90								31		31								90	31	Brand-Name	2	2	Brand-Name																						Brand-Name	45.00	135.00								45.00		45.00	90.00								45.00
H6360	002	0	1	18	06	H6360_002_0	6	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6360	002	0	1	18	06	H6360_002_0	6	2	4	3	Brand-Name	000010	1	2	2			Brand-Name																							Brand-Name			Brand-Name																						Brand-Name																					
H6360	002	0	1	18	06	H6360_002_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H6360	002	0	1	18	06	H6360_002_0	6	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H6360	006	0	1	18	06	H6360_006_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H6360	006	0	1	18	06	H6360_006_0	7	2	4	1	Brand-Name	000010	1	2				Brand-Name	111000000010110000000	31	90								31		31								90	31	Brand-Name	2	2	Brand-Name																						Brand-Name	46.00	138.00								46.00		46.00	92.00								46.00
H6360	006	0	1	18	06	H6360_006_0	7	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H6360	009	0	2	18	06	H6360_009_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H6360	009	0	2	18	06	H6360_009_0	5	2	4	1	Brand-Name	000010	1	2				Brand-Name	111000000010110000000	31	90								31		31								90	31	Brand-Name	2	2	Brand-Name																						Brand-Name	40.00	120.00								40.00		40.00	80.00								40.00
H6360	009	0	2	18	06	H6360_009_0	5	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6360	009	0	2	18	06	H6360_009_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00
H6360	009	0	2	18	06	H6360_009_0	5	2	4	3	Brand-Name	000010	1	2	2			Brand-Name																							Brand-Name			Brand-Name																						Brand-Name																					
H6360	009	0	2	18	06	H6360_009_0	5	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H6411	002	0	1	04	01	H6411_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H6411	002	0	1	04	01	H6411_002_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H6411	002	0	1	04	01	H6411_002_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00
H6411	002	0	1	04	01	H6411_002_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6411	002	0	1	04	01	H6411_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
H6411	002	0	1	04	01	H6411_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H6411	002	0	1	04	01	H6411_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00
H6411	002	0	1	04	01	H6411_002_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6421	007	0	1	09	04	H6421_007_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H6421	007	0	1	09	04	H6421_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H6421	007	0	1	09	04	H6421_007_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H6421	007	0	1	09	04	H6421_007_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H6421	011	0	1	09	04	H6421_011_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H6421	011	0	1	09	04	H6421_011_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H6421	011	0	1	09	04	H6421_011_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H6421	011	0	1	09	04	H6421_011_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H6421	012	0	1	09	04	H6421_012_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H6421	012	0	1	09	04	H6421_012_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H6421	012	0	1	09	04	H6421_012_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H6421	012	0	1	09	04	H6421_012_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H6499	014	0	1	09	04	H6499_014_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H6499	014	0	1	09	04	H6499_014_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H6499	014	0	1	09	04	H6499_014_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H6499	014	0	1	09	04	H6499_014_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
H6499	015	0	1	09	04	H6499_015_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H6499	015	0	1	09	04	H6499_015_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H6499	015	0	1	09	04	H6499_015_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H6499	015	0	1	09	04	H6499_015_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H6499	030	0	1	09	04	H6499_030_0	8	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H6499	030	0	1	09	04	H6499_030_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H6499	030	0	1	09	04	H6499_030_0	8	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H6499	030	0	1	09	04	H6499_030_0	8	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H6499	032	0	1	09	04	H6499_032_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00
H6499	032	0	1	09	04	H6499_032_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00								28.00			84.00								28.00
H6499	032	0	1	09	04	H6499_032_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	58.00	174.00								58.00			174.00								58.00
H6499	032	0	1	09	04	H6499_032_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H6528	001	0	1	04	01	H6528_001_0	8	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
H6528	001	0	1	04	01	H6528_001_0	8	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
H6528	001	0	1	04	01	H6528_001_0	8	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	80.00	240.00								80.00		80.00	240.00								80.00
H6528	001	0	1	04	01	H6528_001_0	8	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
H6621	001	0	1	09	04	H6621_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
H6621	001	0	1	09	04	H6621_001_0	5	4	4	1	Specialty	010001	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	20									20		20									20	Specialty																					
H6621	001	0	1	09	04	H6621_001_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H6621	001	0	1	09	04	H6621_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H6621	001	0	1	09	04	H6621_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H6621	001	0	1	09	04	H6621_001_0	5	4	4	3	Specialty	010001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H6621	001	0	1	09	04	H6621_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H6621	001	0	1	09	04	H6621_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H6793	001	0	1	37	05	H6793_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H6793	001	0	1	37	05	H6793_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H6793	001	0	1	37	05	H6793_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H6793	001	0	1	37	05	H6793_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H6793	003	0	1	37	05	H6793_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00						6.00			9.00		3.00
H6793	003	0	1	37	05	H6793_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00						77.00			87.00		29.00
H6793	003	0	1	37	05	H6793_003_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	60.00	180.00								60.00						170.00			180.00		60.00
H6793	003	0	1	37	05	H6793_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H6900	001	0	1	04	01	H6900_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H6900	001	0	1	04	01	H6900_001_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H6900	001	0	1	04	01	H6900_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H6900	001	0	1	04	01	H6900_001_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6900	001	0	1	04	01	H6900_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H6900	001	0	1	04	01	H6900_001_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H6900	001	0	1	04	01	H6900_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H6900	001	0	1	04	01	H6900_001_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6900	002	0	1	04	01	H6900_002_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6900	002	0	1	04	01	H6900_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H6900	002	0	1	04	01	H6900_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H6900	002	0	1	04	01	H6900_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H6900	002	0	1	04	01	H6900_002_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
H6900	002	0	1	04	01	H6900_002_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
H6900	002	0	1	04	01	H6900_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H6900	002	0	1	04	01	H6900_002_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H6923	001	0	1	01	01	H6923_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H6923	001	0	1	01	01	H6923_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H6923	001	0	1	01	01	H6923_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H6923	001	0	1	01	01	H6923_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H6923	001	0	1	01	01	H6923_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H6923	002	0	1	01	01	H6923_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H6923	002	0	1	01	01	H6923_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H6923	002	0	1	01	01	H6923_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H6923	002	0	1	01	01	H6923_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H6923	002	0	1	01	01	H6923_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H6923	003	0	1	01	01	H6923_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
H6923	003	0	1	01	01	H6923_003_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00
H6923	003	0	1	01	01	H6923_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
H6923	003	0	1	01	01	H6923_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
H6923	003	0	1	01	01	H6923_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H6934	001	0	1	01	01	H6934_001_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000001010000000	30	90									10									90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00									50.00		125.00								50.00
H6934	001	0	1	01	01	H6934_001_0	6	4	4	1	Specialty	000010	1	1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H6934	001	0	1	01	01	H6934_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	0.00	0.00									0.00		0.00								0.00
H6934	001	0	1	01	01	H6934_001_0	6	2	4	1	preferred Brand	000001	1	2				preferred Brand	111000000001010000000	30	90									10									90	31	preferred Brand	2	2	preferred Brand																						preferred Brand	25.00	75.00									25.00		62.50								25.00
H6934	002	0	1	01	01	H6934_002_0	9	4	4	1	Specialty	000010	1	1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	33	33									33		33								33	Specialty																					
H6934	002	0	1	01	01	H6934_002_0	9	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00									60.00		150.00								60.00
H6934	002	0	1	01	01	H6934_002_0	9	1	4	1	Generic	010000	1	2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		12.50								5.00
H6934	002	0	1	01	01	H6934_002_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00		75.00								30.00
H7002	001	0	1	04	01	H7002_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H7002	001	0	1	04	01	H7002_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H7002	001	0	1	04	01	H7002_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H7002	001	0	1	04	01	H7002_001_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H7002	001	0	1	04	01	H7002_001_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7002	001	0	1	04	01	H7002_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H7002	001	0	1	04	01	H7002_001_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7002	001	0	1	04	01	H7002_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H7015	001	0	1	01	01	H7015_001_0	10	4	4	1	Tier 4	010010	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
H7015	001	0	1	01	01	H7015_001_0	10	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00
H7015	001	0	1	01	01	H7015_001_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H7015	001	0	1	01	01	H7015_001_0	10	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H7086	001	0	1	01	01	H7086_001_0	3	2	4	1	Brand	100011	1	2				Brand	111000000010010000000	31	93								31										93	31	Brand	2	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00
H7086	001	0	1	01	01	H7086_001_0	3	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	31	93								31										93	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7146	001	0	1	01	01	H7146_001_0	3	3	4	1	Tier 3 - Brand	000010	1	2				Tier 3 - Brand	111100000001110000000	34	90	10								10	34								90	34	Tier 3 - Brand	2	2	Tier 3 - Brand																						Tier 3 - Brand	25.00	75.00	25.00								25.00	25.00	50.00								25.00
H7146	001	0	1	01	01	H7146_001_0	3	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000001110000000	34	90	10								10	34								90	34	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	15.00	45.00	15.00								15.00	15.00	30.00								15.00
H7146	001	0	1	01	01	H7146_001_0	3	1	4	1	Tier 1 - Generics	010000	1	2				Tier 1 - Generics	111100000001110000000	34	90	10								10	34								90	34	Tier 1 - Generics	2	2	Tier 1 - Generics																						Tier 1 - Generics	3.00	9.00	3.00								3.00	3.00	6.00								3.00
H7146	001	0	1	01	01	H7146_001_0	3	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000001110000000	34	90	10								10	34								90	34	Tier 4 - Specialty	2	1	Tier 4 - Specialty	20	20	20								20	20	20								20	Tier 4 - Specialty																					
H7149	001	0	1	01	01	H7149_001_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H7149	001	0	1	01	01	H7149_001_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7149	001	0	1	01	01	H7149_001_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7149	001	0	1	01	01	H7149_001_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H7149	001	0	1	01	01	H7149_001_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H7149	001	0	1	01	01	H7149_001_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H7149	001	0	1	01	01	H7149_001_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H7149	001	0	1	01	01	H7149_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H7149	002	0	1	01	01	H7149_002_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7149	002	0	1	01	01	H7149_002_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7149	002	0	1	01	01	H7149_002_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H7149	002	0	1	01	01	H7149_002_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H7149	002	0	1	01	01	H7149_002_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H7149	002	0	1	01	01	H7149_002_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H7149	002	0	1	01	01	H7149_002_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H7149	002	0	1	01	01	H7149_002_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H7179	001	0	1	01	01	H7179_001_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H7179	001	0	1	01	01	H7179_001_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H7179	001	0	1	01	01	H7179_001_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	001	0	1	01	01	H7179_001_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H7179	001	0	1	01	01	H7179_001_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H7179	001	0	1	01	01	H7179_001_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H7179	001	0	1	01	01	H7179_001_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	001	0	1	01	01	H7179_001_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H7179	002	0	1	01	01	H7179_002_0	7	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H7179	002	0	1	01	01	H7179_002_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H7179	002	0	1	01	01	H7179_002_0	7	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	002	0	1	01	01	H7179_002_0	7	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H7179	002	0	1	01	01	H7179_002_0	7	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H7179	002	0	1	01	01	H7179_002_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H7179	002	0	1	01	01	H7179_002_0	7	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	002	0	1	01	01	H7179_002_0	7	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H7179	007	0	1	01	01	H7179_007_0	7	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	007	0	1	01	01	H7179_007_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H7179	007	0	1	01	01	H7179_007_0	7	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H7179	007	0	1	01	01	H7179_007_0	7	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H7179	007	0	1	01	01	H7179_007_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H7179	007	0	1	01	01	H7179_007_0	7	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	007	0	1	01	01	H7179_007_0	7	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H7179	007	0	1	01	01	H7179_007_0	7	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H7179	009	0	1	02	01	H7179_009_0	9	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	009	0	1	02	01	H7179_009_0	9	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
H7179	009	0	1	02	01	H7179_009_0	9	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H7179	009	0	1	02	01	H7179_009_0	9	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111000000010000010010	30	90								30					90			90			31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00						0.00			0.00		0.00
H7179	009	0	1	02	01	H7179_009_0	9	4	4	1	Tier 4 - Specialty Drug	000010	1	1				Tier 4 - Specialty Drug	111000000010000010010	30	90								30					90			90			31	Tier 4 - Specialty Drug	2	4	Tier 4 - Specialty Drug	25	25								25						25			25		25	Tier 4 - Specialty Drug	200.00	600.00								200.00						600.00			600.00		200.00
H7179	009	0	1	02	01	H7179_009_0	9	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00						120.00			180.00		60.00
H7179	009	0	1	02	01	H7179_009_0	9	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010000010010	30	90								30					90			90			31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00								35.00						70.00			105.00		35.00
H7179	009	0	1	02	01	H7179_009_0	9	4	4	3	Tier 4 - Specialty Drug	000010	1	1	2			Tier 4 - Specialty Drug																							Tier 4 - Specialty Drug			Tier 4 - Specialty Drug																						Tier 4 - Specialty Drug																					
H7187	001	0	1	02	01	H7187_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H7187	001	0	1	02	01	H7187_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H7187	001	0	1	02	01	H7187_001_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H7187	001	0	1	02	01	H7187_001_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	003	0	1	02	01	H7187_003_0	10	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
H7187	003	0	1	02	01	H7187_003_0	10	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H7187	003	0	1	02	01	H7187_003_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H7187	003	0	1	02	01	H7187_003_0	10	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	006	0	1	02	01	H7187_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	006	0	1	02	01	H7187_006_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H7187	006	0	1	02	01	H7187_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H7187	006	0	1	02	01	H7187_006_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H7187	007	0	1	02	01	H7187_007_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H7187	007	0	1	02	01	H7187_007_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00
H7187	007	0	1	02	01	H7187_007_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	85.00	255.00								85.00						245.00			255.00		85.00
H7187	007	0	1	02	01	H7187_007_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	008	0	1	02	01	H7187_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	008	0	1	02	01	H7187_008_0	3	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
H7187	008	0	1	02	01	H7187_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
H7187	008	0	1	02	01	H7187_008_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H7187	009	0	1	02	01	H7187_009_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H7187	009	0	1	02	01	H7187_009_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H7187	009	0	1	02	01	H7187_009_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H7187	009	0	1	02	01	H7187_009_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
H7188	001	0	1	04	01	H7188_001_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H7188	001	0	1	04	01	H7188_001_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H7188	001	0	1	04	01	H7188_001_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7188	001	0	1	04	01	H7188_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H7188	001	0	1	04	01	H7188_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H7188	001	0	1	04	01	H7188_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H7188	001	0	1	04	01	H7188_001_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7188	001	0	1	04	01	H7188_001_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H7188	003	0	1	04	01	H7188_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H7188	003	0	1	04	01	H7188_003_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H7188	003	0	1	04	01	H7188_003_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H7188	003	0	1	04	01	H7188_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H7188	003	0	1	04	01	H7188_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H7188	003	0	1	04	01	H7188_003_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7188	003	0	1	04	01	H7188_003_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H7188	003	0	1	04	01	H7188_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H7200	006	0	1	01	01	H7200_006_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H7200	006	0	1	01	01	H7200_006_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H7200	006	0	1	01	01	H7200_006_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	67.50							90.00		90.00	180.00	67.50							90.00
H7200	006	0	1	01	01	H7200_006_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H7200	007	0	1	01	01	H7200_007_0	8	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H7200	007	0	1	01	01	H7200_007_0	8	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H7200	007	0	1	01	01	H7200_007_0	8	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	60.00	120.00	90.00							60.00		60.00	120.00	90.00							60.00
H7200	007	0	1	01	01	H7200_007_0	8	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H7200	011	0	1	02	01	H7200_011_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	3.00	6.00	4.50							3.00		3.00	6.00	4.50							3.00
H7200	011	0	1	02	01	H7200_011_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H7200	011	0	1	02	01	H7200_011_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	60.00	120.00	90.00							60.00		60.00	120.00	90.00							60.00
H7200	011	0	1	02	01	H7200_011_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H7220	003	0	1	01	01	H7220_003_0	9	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	77.50	193.75								77.50		77.50	193.75								77.50
H7220	003	0	1	01	01	H7220_003_0	9	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.50	93.75								37.50		37.50	93.75								37.50
H7220	003	0	1	01	01	H7220_003_0	9	1	3	1	Generic	010000		2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	25.00								10.00		10.00	25.00								10.00
H7220	003	0	1	01	01	H7220_003_0	9	4	3	1	Specialty	000011		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	30									30		30									30	Specialty																					
H7220	004	0	1	02	01	H7220_004_0	11	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	20.00								10.00		10.00	20.00								10.00
H7220	004	0	1	02	01	H7220_004_0	11	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7220	004	0	1	02	01	H7220_004_0	11	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H7220	004	0	1	02	01	H7220_004_0	11	4	4	1	Specialty	110001	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	30									30		30									30	Specialty																					
H7220	004	0	1	02	01	H7220_004_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00		70.00	140.00								70.00
H7220	004	0	1	02	01	H7220_004_0	11	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H7220	004	0	1	02	01	H7220_004_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	10.00	20.00								10.00		10.00	20.00								10.00
H7220	004	0	1	02	01	H7220_004_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00		30.00	60.00								30.00
H7226	001	0	1	09	04	H7226_001_0	5	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	001	0	1	09	04	H7226_001_0	5	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H7226	001	0	1	09	04	H7226_001_0	5	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00
H7226	001	0	1	09	04	H7226_001_0	5	1	4	3	Tier 1	010001	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	001	0	1	09	04	H7226_001_0	5	2	4	3	Tier 2	010001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H7226	001	0	1	09	04	H7226_001_0	5	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H7226	002	0	1	09	04	H7226_002_0	8	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	002	0	1	09	04	H7226_002_0	8	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H7226	002	0	1	09	04	H7226_002_0	8	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00
H7226	007	0	1	09	04	H7226_007_0	6	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H7226	007	0	1	09	04	H7226_007_0	6	1	4	3	Tier 1	010001	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	007	0	1	09	04	H7226_007_0	6	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H7226	007	0	1	09	04	H7226_007_0	6	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	007	0	1	09	04	H7226_007_0	6	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00
H7226	007	0	1	09	04	H7226_007_0	6	2	4	3	Tier 2	010001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H7226	008	0	1	09	04	H7226_008_0	7	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00
H7226	008	0	1	09	04	H7226_008_0	7	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H7226	008	0	1	09	04	H7226_008_0	7	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	011	0	1	09	04	H7226_011_0	4	3	4	3	Tier 3	000010	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H7226	011	0	1	09	04	H7226_011_0	4	2	4	3	Tier 2	010001	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H7226	011	0	1	09	04	H7226_011_0	4	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00
H7226	011	0	1	09	04	H7226_011_0	4	1	4	3	Tier 1	010001	3	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	011	0	1	09	04	H7226_011_0	4	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00
H7226	011	0	1	09	04	H7226_011_0	4	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	013	0	1	09	04	H7226_013_0	7	3	4	1	Tier 3	000010	3	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00
H7226	013	0	1	09	04	H7226_013_0	7	1	4	1	Tier 1	010001	3	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00
H7226	013	0	1	09	04	H7226_013_0	7	2	4	1	Tier 2	010001	3	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H7252	002	0	1	01	01	H7252_002_0	6	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7252	002	0	1	01	01	H7252_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7252	002	0	1	01	01	H7252_002_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H7252	002	0	1	01	01	H7252_002_0	6	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7252	002	0	1	01	01	H7252_002_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H7252	002	0	1	01	01	H7252_002_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H7252	002	0	1	01	01	H7252_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H7252	002	0	1	01	01	H7252_002_0	6	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H7252	003	0	1	01	01	H7252_003_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H7252	003	0	1	01	01	H7252_003_0	6	3	4	1	Non Preferred Brand	100000	1	2				Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
H7252	003	0	1	01	01	H7252_003_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	110000000010100000000	30									30		30									31	Specialty Drugs	2	1	Specialty Drugs	20									20		20									20	Specialty Drugs																					
H7252	003	0	1	01	01	H7252_003_0	6	1	4	3	Generic	011100	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7252	003	0	1	01	01	H7252_003_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7252	003	0	1	01	01	H7252_003_0	6	3	4	3	Non Preferred Brand	100000	1	2	2			Non Preferred Brand																							Non Preferred Brand			Non Preferred Brand																						Non Preferred Brand																					
H7252	003	0	1	01	01	H7252_003_0	6	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H7252	003	0	1	01	01	H7252_003_0	6	1	4	1	Generic	011100	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7292	001	0	1	01	01	H7292_001_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	40.00	120.00								40.00			120.00								40.00
H7292	001	0	1	01	01	H7292_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7292	001	0	1	01	01	H7292_001_0	5	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	2	Specialty																						Specialty	85.00	255.00								85.00			255.00								85.00
H7301	001	0	1	04	01	H7301_001_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H7301	001	0	1	04	01	H7301_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H7301	001	0	1	04	01	H7301_001_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H7301	001	0	1	04	01	H7301_001_0	4	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H7301	001	0	1	04	01	H7301_001_0	4	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H7301	001	0	1	04	01	H7301_001_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H7301	001	0	1	04	01	H7301_001_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7301	001	0	1	04	01	H7301_001_0	4	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7301	002	0	1	04	01	H7301_002_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H7301	002	0	1	04	01	H7301_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7301	002	0	1	04	01	H7301_002_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7301	002	0	1	04	01	H7301_002_0	3	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H7301	002	0	1	04	01	H7301_002_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H7301	002	0	1	04	01	H7301_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H7301	002	0	1	04	01	H7301_002_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H7301	002	0	1	04	01	H7301_002_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H7306	001	0	1	04	01	H7306_001_0	9	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7306	001	0	1	04	01	H7306_001_0	9	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H7306	001	0	1	04	01	H7306_001_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H7306	001	0	1	04	01	H7306_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H7306	001	0	1	04	01	H7306_001_0	9	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7306	001	0	1	04	01	H7306_001_0	9	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H7306	001	0	1	04	01	H7306_001_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7306	001	0	1	04	01	H7306_001_0	9	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7306	002	0	1	04	01	H7306_002_0	9	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H7306	002	0	1	04	01	H7306_002_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7306	002	0	1	04	01	H7306_002_0	9	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7306	002	0	1	04	01	H7306_002_0	9	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H7306	002	0	1	04	01	H7306_002_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H7306	002	0	1	04	01	H7306_002_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H7306	002	0	1	04	01	H7306_002_0	9	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7306	002	0	1	04	01	H7306_002_0	9	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H7406	001	0	1	09	04	H7406_001_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H7406	001	0	1	09	04	H7406_001_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H7406	001	0	1	09	04	H7406_001_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H7406	001	0	1	09	04	H7406_001_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H7406	004	0	1	09	04	H7406_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H7406	004	0	1	09	04	H7406_004_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H7406	004	0	1	09	04	H7406_004_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H7406	004	0	1	09	04	H7406_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H7406	007	0	1	09	04	H7406_007_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H7406	007	0	1	09	04	H7406_007_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H7406	007	0	1	09	04	H7406_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H7406	007	0	1	09	04	H7406_007_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00
H7406	009	0	1	09	04	H7406_009_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H7406	009	0	1	09	04	H7406_009_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H7406	009	0	1	09	04	H7406_009_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H7406	009	0	1	09	04	H7406_009_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H7406	010	0	1	09	04	H7406_010_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	31	90								31		31								90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00
H7406	010	0	1	09	04	H7406_010_0	3	3	4	1	Non-Preferred Brand	110010	1	2				Non-Preferred Brand	111000000010110000000	31	90								31		31								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H7406	010	0	1	09	04	H7406_010_0	3	2	4	1	Preferred Brand	010011	1	2				Preferred Brand	111000000010110000000	31	90								31		31								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00
H7406	010	0	1	09	04	H7406_010_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	31	90								31		31								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H7526	001	0	1	01	01	H7526_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00
H7526	001	0	1	01	01	H7526_001_0	11	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	67.00	201.00								67.00			134.00								67.00
H7526	001	0	1	01	01	H7526_001_0	11	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	31	90								31										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H7526	001	0	1	01	01	H7526_001_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H7568	001	0	1	04	01	H7568_001_0	6	1	4	1	Generic	011000	1	2				Generic	111000000001010000000	31	90									10									90	31	Generic	2	2	Generic																						Generic	5.00	15.00									5.00		10.00								5.00
H7568	001	0	1	04	01	H7568_001_0	6	2	4	1	Preferred Brand	000011	1	2				Preferred Brand	111000000001010000000	31	90									10									90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00									40.00		80.00								40.00
H7568	001	0	1	04	01	H7568_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000001010000000	31	90									10									90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00									70.00		140.00								70.00
H7568	001	0	1	04	01	H7568_001_0	6	4	4	1	Specialty	100011	1	1				Specialty	110000000001000000000	31										10										31	Specialty	2	1	Specialty	25										25										25	Specialty																					
H7678	001	0	1	01	01	H7678_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00			117.00								39.00
H7678	001	0	1	01	01	H7678_001_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H7678	001	0	1	01	01	H7678_001_0	5	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00			231.00								77.00
H7678	001	0	1	01	01	H7678_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H7678	002	0	1	01	01	H7678_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H7678	002	0	1	01	01	H7678_002_0	6	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H7678	002	0	1	01	01	H7678_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00
H7678	002	0	1	01	01	H7678_002_0	6	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
H7692	001	0	1	04	01	H7692_001_0	9	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H7692	001	0	1	04	01	H7692_001_0	9	3	4	1	Non-Preferred Generic/Non-preferred brand	100100	1	2				Non-Preferred Generic/Non-preferred brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-preferred brand	2	2	Non-Preferred Generic/Non-preferred brand																						Non-Preferred Generic/Non-preferred brand	75.00	225.00								75.00			225.00								75.00
H7692	001	0	1	04	01	H7692_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00			70.00								35.00
H7692	001	0	1	04	01	H7692_001_0	9	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H7731	001	0	1	01	01	H7731_001_0	7	1	4	1	Tier 1	010000	3	2				Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00
H7731	001	0	1	01	01	H7731_001_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000001010000000	30	90									10									90	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00									15.00		30.00								15.00
H7731	001	0	1	01	01	H7731_001_0	7	3	4	1	Tier 3	000010	1	2				Tier 3	111000000001010000000	30	90									10									90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00									50.00		100.00								50.00
H7731	001	0	1	01	01	H7731_001_0	7	4	4	1	Tier 4	010011	1	1				Tier 4	111000000001010000000	30	90									10									90	31	Tier 4	2	1	Tier 4	25	25									25		25								25	Tier 4																					
H7731	001	0	1	01	01	H7731_001_0	7	1	4	3	Tier 1	010000	3	2	1		1	Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00
H7731	001	0	1	01	01	H7731_001_0	7	2	4	3	Tier 2	000001	1	2	1		1	Tier 2	111000000001010000000	30	90									10									90	31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00									15.00		30.00								15.00
H7731	001	0	1	01	01	H7731_001_0	7	3	4	3	Tier 3	000010	1	2	1		1	Tier 3	111000000001010000000	30	90									10									90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00									50.00		100.00								50.00
H7731	001	0	1	01	01	H7731_001_0	7	4	4	3	Tier 4	010011	1	1	1		1	Tier 4	111000000001010000000	30	90									10									90	31	Tier 4	2	1	Tier 4	25	25									25		25								25	Tier 4																					
H7787	001	0	1	04	01	H7787_001_0	3	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H7787	001	0	1	04	01	H7787_001_0	3	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H7787	001	0	1	04	01	H7787_001_0	3	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7787	001	0	1	04	01	H7787_001_0	3	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H7787	001	0	1	04	01	H7787_001_0	3	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7787	001	0	1	04	01	H7787_001_0	3	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H7787	001	0	1	04	01	H7787_001_0	3	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H7787	001	0	1	04	01	H7787_001_0	3	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H7787	001	0	1	04	01	H7787_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7787	001	0	1	04	01	H7787_001_0	3	2	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H7787	003	0	1	04	01	H7787_003_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H7787	003	0	1	04	01	H7787_003_0	4	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H7787	003	0	1	04	01	H7787_003_0	4	2	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H7787	003	0	1	04	01	H7787_003_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7787	003	0	1	04	01	H7787_003_0	4	3	4	3	Preferred Brand	000001	3	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H7787	003	0	1	04	01	H7787_003_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H7787	003	0	1	04	01	H7787_003_0	4	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
H7787	003	0	1	04	01	H7787_003_0	4	2	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00
H7787	003	0	1	04	01	H7787_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H7787	003	0	1	04	01	H7787_003_0	4	5	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H7908	001	0	1	01	01	H7908_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H7908	001	0	1	01	01	H7908_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00
H7908	001	0	1	01	01	H7908_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
H7908	001	0	1	01	01	H7908_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00
H7908	001	0	1	01	01	H7908_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H7908	002	0	1	01	01	H7908_002_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H7908	002	0	1	01	01	H7908_002_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H7908	002	0	1	01	01	H7908_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H7908	002	0	1	01	01	H7908_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H7908	002	0	1	01	01	H7908_002_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H7908	002	0	1	01	01	H7908_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H7908	002	0	1	01	01	H7908_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H7908	002	0	1	01	01	H7908_002_0	4	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H7908	002	0	1	01	01	H7908_002_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H7908	002	0	1	01	01	H7908_002_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H7917	004	0	1	04	01	H7917_004_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	004	0	1	04	01	H7917_004_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	004	0	1	04	01	H7917_004_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	004	0	1	04	01	H7917_004_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	005	0	1	04	01	H7917_005_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	005	0	1	04	01	H7917_005_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	005	0	1	04	01	H7917_005_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	005	0	1	04	01	H7917_005_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	006	0	1	04	01	H7917_006_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	006	0	1	04	01	H7917_006_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	006	0	1	04	01	H7917_006_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	006	0	1	04	01	H7917_006_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	007	0	1	04	01	H7917_007_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	007	0	1	04	01	H7917_007_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	007	0	1	04	01	H7917_007_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	007	0	1	04	01	H7917_007_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	008	0	1	04	01	H7917_008_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	008	0	1	04	01	H7917_008_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	008	0	1	04	01	H7917_008_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	008	0	1	04	01	H7917_008_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	009	0	1	04	01	H7917_009_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	009	0	1	04	01	H7917_009_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	009	0	1	04	01	H7917_009_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	009	0	1	04	01	H7917_009_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	010	0	1	04	01	H7917_010_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	010	0	1	04	01	H7917_010_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	010	0	1	04	01	H7917_010_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H7917	010	0	1	04	01	H7917_010_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	011	0	1	04	01	H7917_011_0	7	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50								55.00
H7917	011	0	1	04	01	H7917_011_0	7	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50								5.00
H7917	011	0	1	04	01	H7917_011_0	7	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00		30.00	75.00								30.00
H7917	011	0	1	04	01	H7917_011_0	7	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010110000000	30	90								30		30								90	31	Tier 4	2	1	Tier 4	33	33								33		33	33								33	Tier 4																					
H8031	001	0	1	01	01	H8031_001_0	4	1	4	1	Tier 1	010000	1	2				Tier 1	110000000010000000000	30									30											31	Tier 1	2	2	Tier 1																						Tier 1	0.00									0.00											0.00
H8031	001	0	1	01	01	H8031_001_0	4	4	4	1	Tier 4	000010	1	1				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	25									25											25	Tier 4																					
H8031	001	0	1	01	01	H8031_001_0	4	3	4	1	Tier 3	000010	1	2				Tier 3	110000000010000000000	30									30											31	Tier 3	2	2	Tier 3																						Tier 3	98.00									98.00											98.00
H8031	001	0	1	01	01	H8031_001_0	4	2	4	1	Tier 2	000010	1	2				Tier 2	110000000010000000000	30									30											31	Tier 2	2	2	Tier 2																						Tier 2	47.00									47.00											47.00
H8172	003	0	1	04	01	H8172_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H8172	003	0	1	04	01	H8172_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H8172	003	0	1	04	01	H8172_003_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8172	003	0	1	04	01	H8172_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8172	003	0	1	04	01	H8172_003_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8172	003	0	1	04	01	H8172_003_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H8172	003	0	1	04	01	H8172_003_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H8172	003	0	1	04	01	H8172_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H8172	004	0	1	04	01	H8172_004_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8172	004	0	1	04	01	H8172_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8172	004	0	1	04	01	H8172_004_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8172	004	0	1	04	01	H8172_004_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H8172	004	0	1	04	01	H8172_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H8172	004	0	1	04	01	H8172_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H8172	004	0	1	04	01	H8172_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H8172	004	0	1	04	01	H8172_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H8189	001	0	1	01	01	H8189_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H8189	001	0	1	01	01	H8189_001_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	44.00	132.00								44.00			132.00								44.00
H8189	001	0	1	01	01	H8189_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	83.00	249.00								83.00			249.00								83.00
H8189	001	0	1	01	01	H8189_001_0	6	4	4	1	Injectable	000001	1	2				Injectable	111000000010010000000	30	90								30										90	31	Injectable	2	2	Injectable																						Injectable	44.00	132.00								44.00			132.00								44.00
H8239	001	0	1	04	01	H8239_001_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H8239	001	0	1	04	01	H8239_001_0	11	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	30									30											30	Specialty- Generic and Brand																					
H8239	001	0	1	04	01	H8239_001_0	11	3	4	1	Non-Preferred Generic/ Non-preferred brand	101000	1	2				Non-Preferred Generic/ Non-preferred brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/ Non-preferred brand	2	2	Non-Preferred Generic/ Non-preferred brand																						Non-Preferred Generic/ Non-preferred brand	65.00	195.00								65.00			195.00								65.00
H8239	001	0	1	04	01	H8239_001_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H8393	001	0	1	04	01	H8393_001_0	10	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8393	001	0	1	04	01	H8393_001_0	10	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
H8393	001	0	1	04	01	H8393_001_0	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
H8393	001	0	1	04	01	H8393_001_0	10	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H8393	001	0	1	04	01	H8393_001_0	10	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8393	001	0	1	04	01	H8393_001_0	10	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8393	001	0	1	04	01	H8393_001_0	10	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H8393	001	0	1	04	01	H8393_001_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8578	001	0	1	01	01	H8578_001_0	7	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	001	0	1	01	01	H8578_001_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H8578	001	0	1	01	01	H8578_001_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
H8578	001	0	1	01	01	H8578_001_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	20.00	60.00								20.00			40.00								20.00
H8578	001	0	1	01	01	H8578_001_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	001	0	1	01	01	H8578_001_0	7	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H8578	001	0	1	01	01	H8578_001_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8578	001	0	1	01	01	H8578_001_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8578	002	0	1	01	01	H8578_002_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H8578	002	0	1	01	01	H8578_002_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00
H8578	002	0	1	01	01	H8578_002_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H8578	002	0	1	01	01	H8578_002_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H8578	004	0	1	01	01	H8578_004_0	7	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	004	0	1	01	01	H8578_004_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H8578	004	0	1	01	01	H8578_004_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
H8578	004	0	1	01	01	H8578_004_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	20.00	60.00								20.00			40.00								20.00
H8578	004	0	1	01	01	H8578_004_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	004	0	1	01	01	H8578_004_0	7	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H8578	004	0	1	01	01	H8578_004_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8578	004	0	1	01	01	H8578_004_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8578	005	0	1	01	01	H8578_005_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00
H8578	005	0	1	01	01	H8578_005_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H8578	005	0	1	01	01	H8578_005_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H8578	005	0	1	01	01	H8578_005_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H8578	007	0	1	01	01	H8578_007_0	7	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
H8578	007	0	1	01	01	H8578_007_0	7	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	20.00	60.00								20.00			40.00								20.00
H8578	007	0	1	01	01	H8578_007_0	7	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	007	0	1	01	01	H8578_007_0	7	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H8578	007	0	1	01	01	H8578_007_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8578	007	0	1	01	01	H8578_007_0	7	3	4	3	Non-Preferred Brand	100000	3	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8578	007	0	1	01	01	H8578_007_0	7	2	4	3	Brand	000001	1	2	2			Brand																							Brand			Brand																						Brand																					
H8578	007	0	1	01	01	H8578_007_0	7	1	4	3	Generic	010000	3	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H8578	008	0	1	01	01	H8578_008_0	6	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00
H8578	008	0	1	01	01	H8578_008_0	6	1	4	1	Generic	010000	3	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
H8578	008	0	1	01	01	H8578_008_0	6	2	4	1	Brand	000001	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H8578	008	0	1	01	01	H8578_008_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H8604	001	0	1	04	01	H8604_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H8604	001	0	1	04	01	H8604_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H8604	001	0	1	04	01	H8604_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
H8604	001	0	1	04	01	H8604_001_0	7	4	4	1	Specialty	010001	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	20									20		20									20	Specialty																					
H8604	001	0	1	04	01	H8604_001_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H8604	001	0	1	04	01	H8604_001_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8604	001	0	1	04	01	H8604_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8604	001	0	1	04	01	H8604_001_0	7	4	4	3	Specialty	010001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8604	003	0	1	04	01	H8604_003_0	7	4	4	3	Specialty	010001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8604	003	0	1	04	01	H8604_003_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8604	003	0	1	04	01	H8604_003_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H8604	003	0	1	04	01	H8604_003_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
H8604	003	0	1	04	01	H8604_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
H8604	003	0	1	04	01	H8604_003_0	7	4	4	1	Specialty	010001	1	1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	20									20		20									20	Specialty																					
H8604	003	0	1	04	01	H8604_003_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
H8604	003	0	1	04	01	H8604_003_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8644	001	0	1	04	01	H8644_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H8644	001	0	1	04	01	H8644_001_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H8644	001	0	1	04	01	H8644_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H8644	001	0	1	04	01	H8644_001_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8644	001	0	1	04	01	H8644_001_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H8644	001	0	1	04	01	H8644_001_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H8644	001	0	1	04	01	H8644_001_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H8644	001	0	1	04	01	H8644_001_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8644	003	0	1	04	01	H8644_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H8644	003	0	1	04	01	H8644_003_0	3	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8644	003	0	1	04	01	H8644_003_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H8644	003	0	1	04	01	H8644_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H8644	003	0	1	04	01	H8644_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H8644	003	0	1	04	01	H8644_003_0	3	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8644	003	0	1	04	01	H8644_003_0	3	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00
H8644	003	0	1	04	01	H8644_003_0	3	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H8649	001	0	1	02	01	H8649_001_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8649	001	0	1	02	01	H8649_001_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8649	001	0	1	02	01	H8649_001_0	4	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H8649	001	0	1	02	01	H8649_001_0	4	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H8649	001	0	1	02	01	H8649_001_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8649	001	0	1	02	01	H8649_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H8649	001	0	1	02	01	H8649_001_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	51.00	153.00								51.00			153.00								51.00
H8649	001	0	1	02	01	H8649_001_0	4	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	002	0	1	02	01	H8649_002_0	4	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H8649	002	0	1	02	01	H8649_002_0	4	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H8649	002	0	1	02	01	H8649_002_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H8649	002	0	1	02	01	H8649_002_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8649	002	0	1	02	01	H8649_002_0	4	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	002	0	1	02	01	H8649_002_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H8649	002	0	1	02	01	H8649_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H8649	002	0	1	02	01	H8649_002_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H8649	003	0	1	02	01	H8649_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H8649	003	0	1	02	01	H8649_003_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
H8649	003	0	1	02	01	H8649_003_0	4	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	003	0	1	02	01	H8649_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
H8649	004	0	1	02	01	H8649_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H8649	004	0	1	02	01	H8649_004_0	5	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
H8649	004	0	1	02	01	H8649_004_0	5	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H8649	004	0	1	02	01	H8649_004_0	5	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H8649	004	0	1	02	01	H8649_004_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8649	004	0	1	02	01	H8649_004_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8649	004	0	1	02	01	H8649_004_0	5	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	004	0	1	02	01	H8649_004_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	6.00								3.00			6.00								3.00
H8649	005	0	1	02	01	H8649_005_0	4	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H8649	005	0	1	02	01	H8649_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
H8649	005	0	1	02	01	H8649_005_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H8649	005	0	1	02	01	H8649_005_0	4	4	4	1	Specialty - Generic and Brand	010010	1	1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	005	0	1	02	01	H8649_005_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8649	005	0	1	02	01	H8649_005_0	4	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
H8649	005	0	1	02	01	H8649_005_0	4	4	4	3	Specialty - Generic and Brand	010010	1	1	2			Specialty - Generic and Brand																							Specialty - Generic and Brand			Specialty - Generic and Brand																						Specialty - Generic and Brand																					
H8649	005	0	1	02	01	H8649_005_0	4	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
H8649	006	0	1	02	01	H8649_006_0	4	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
H8649	006	0	1	02	01	H8649_006_0	4	4	3	1	Specialty - Generic and Brand	010010		1				Specialty - Generic and Brand	110000000010000000000	30									30											31	Specialty - Generic and Brand	2	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																					
H8649	006	0	1	02	01	H8649_006_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
H8649	006	0	1	02	01	H8649_006_0	4	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	68.00	204.00								68.00			204.00								68.00
H8707	001	0	1	04	01	H8707_001_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	001	0	1	04	01	H8707_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	001	0	1	04	01	H8707_001_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8707	001	0	1	04	01	H8707_001_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	001	0	1	04	01	H8707_001_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	001	0	1	04	01	H8707_001_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	001	0	1	04	01	H8707_001_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8707	001	0	1	04	01	H8707_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	003	0	1	04	01	H8707_003_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	003	0	1	04	01	H8707_003_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	003	0	1	04	01	H8707_003_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	003	0	1	04	01	H8707_003_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	003	0	1	04	01	H8707_003_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8707	003	0	1	04	01	H8707_003_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	003	0	1	04	01	H8707_003_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	003	0	1	04	01	H8707_003_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8707	005	0	1	04	01	H8707_005_0	4	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	005	0	1	04	01	H8707_005_0	4	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	005	0	1	04	01	H8707_005_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	005	0	1	04	01	H8707_005_0	4	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8707	005	0	1	04	01	H8707_005_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00
H8707	005	0	1	04	01	H8707_005_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00
H8707	005	0	1	04	01	H8707_005_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00								68.00					68.00	170.00		68.00	204.00		68.00
H8707	005	0	1	04	01	H8707_005_0	4	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H8742	001	0	1	01	01	H8742_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H8742	001	0	1	01	01	H8742_001_0	6	2	4	1	Preferred  Brand	000001	1	2				Preferred  Brand	111000000010000000000	31	90								31											31	Preferred  Brand	2	2	Preferred  Brand																						Preferred  Brand	35.00	87.50								35.00											35.00
H8742	001	0	1	01	01	H8742_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H8742	001	0	1	01	01	H8742_001_0	6	4	4	1	Speciality	110001	1	1				Speciality	110000000010000000000	31									31											31	Speciality	2	1	Speciality	25									25											25	Speciality																					
H8742	008	0	1	01	01	H8742_008_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H8742	008	0	1	01	01	H8742_008_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	31	90								31											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00											30.00
H8742	008	0	1	01	01	H8742_008_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H8742	008	0	1	01	01	H8742_008_0	7	4	4	1	Specialty	110001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H8742	008	0	1	01	01	H8742_008_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
H8742	008	0	1	01	01	H8742_008_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8742	008	0	1	01	01	H8742_008_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8742	008	0	1	01	01	H8742_008_0	7	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8742	010	0	1	01	01	H8742_010_0	7	4	4	3	Speciality	110001	1	1	2			Speciality																							Speciality			Speciality																						Speciality																					
H8742	010	0	1	01	01	H8742_010_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H8742	010	0	1	01	01	H8742_010_0	7	2	4	1	Preferred  Brand	000001	1	2				Preferred  Brand	111000000010000000000	31	90								31											31	Preferred  Brand	2	2	Preferred  Brand																						Preferred  Brand	35.00	87.50								35.00											35.00
H8742	010	0	1	01	01	H8742_010_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	31	90								31											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	150.00								60.00											60.00
H8742	010	0	1	01	01	H8742_010_0	7	4	4	1	Speciality	110001	1	1				Speciality	110000000010000000000	31									31											31	Speciality	2	1	Speciality	25									25											25	Speciality																					
H8742	010	0	1	01	01	H8742_010_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	31	90								31											31	Generic	2	2	Generic																						Generic	5.00	12.50								5.00											5.00
H8742	010	0	1	01	01	H8742_010_0	7	2	4	3	Preferred  Brand	000001	1	2	2			Preferred  Brand																							Preferred  Brand			Preferred  Brand																						Preferred  Brand																					
H8742	010	0	1	01	01	H8742_010_0	7	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8748	001	0	1	02	01	H8748_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H8748	001	0	1	02	01	H8748_001_0	6	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H8748	001	0	1	02	01	H8748_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H8748	001	0	1	02	01	H8748_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00						86.00			96.00		32.00
H8748	002	0	1	02	01	H8748_002_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H8748	002	0	1	02	01	H8748_002_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8748	002	0	1	02	01	H8748_002_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H8748	002	0	1	02	01	H8748_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H8748	002	0	1	02	01	H8748_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H8748	002	0	1	02	01	H8748_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H8748	002	0	1	02	01	H8748_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H8748	002	0	1	02	01	H8748_002_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8748	003	0	1	02	01	H8748_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00						4.00			6.00		2.00
H8748	003	0	1	02	01	H8748_003_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H8748	003	0	1	02	01	H8748_003_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H8748	003	0	1	02	01	H8748_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H8748	004	0	1	02	01	H8748_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H8748	004	0	1	02	01	H8748_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H8748	004	0	1	02	01	H8748_004_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H8748	004	0	1	02	01	H8748_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H8778	001	0	1	01	01	H8778_001_0	9	1	4	1	Tier 1 Generic	010000	1	2				Tier 1 Generic	111000000010110000000	31	93								31		31								93	34	Tier 1 Generic	2	2	Tier 1 Generic																						Tier 1 Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8778	001	0	1	01	01	H8778_001_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	87.00								29.00		29.00	58.00								29.00
H8778	001	0	1	01	01	H8778_001_0	9	3	4	1	Tier 3 Non-Preferred Brand	100000	1	2				Tier 3 Non-Preferred Brand	111000000010110000000	31	93								31		31								93	34	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	59.00	177.00								59.00		59.00	118.00								59.00
H8778	001	0	1	01	01	H8778_001_0	9	4	4	1	Tier 4 Specialty	100011	1	1				Tier 4 Specialty	111000000010110000000	31	93								31		31								93	34	Tier 4 Specialty	2	1	Tier 4 Specialty	20	20								20		20	20								20	Tier 4 Specialty																					
H8805	001	0	1	04	01	H8805_001_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H8805	001	0	1	04	01	H8805_001_0	9	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H8805	001	0	1	04	01	H8805_001_0	9	3	4	1	Brand	100000	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H8805	001	0	1	04	01	H8805_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H8805	001	0	1	04	01	H8805_001_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H8805	001	0	1	04	01	H8805_001_0	9	2	4	3	Preferred	000001	1	2	2			Preferred																							Preferred			Preferred																						Preferred																					
H8805	001	0	1	04	01	H8805_001_0	9	3	4	3	Brand	100000	1	2	2			Brand																							Brand			Brand																						Brand																					
H8805	001	0	1	04	01	H8805_001_0	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8822	001	0	1	01	01	H8822_001_0	8	5	3	1	Specialty	000010		1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H8822	001	0	1	01	01	H8822_001_0	8	4	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		90.00	180.00								90.00
H8822	001	0	1	01	01	H8822_001_0	8	3	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H8822	001	0	1	01	01	H8822_001_0	8	2	3	1	Generic	010000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	001	0	1	01	01	H8822_001_0	8	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	002	0	1	01	01	H8822_002_0	5	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H8822	002	0	1	01	01	H8822_002_0	5	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8822	002	0	1	01	01	H8822_002_0	5	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8822	002	0	1	01	01	H8822_002_0	5	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8822	002	0	1	01	01	H8822_002_0	5	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	002	0	1	01	01	H8822_002_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8822	002	0	1	01	01	H8822_002_0	5	5	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H8822	002	0	1	01	01	H8822_002_0	5	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H8822	002	0	1	01	01	H8822_002_0	5	2	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	002	0	1	01	01	H8822_002_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8822	003	0	1	01	01	H8822_003_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H8822	003	0	1	01	01	H8822_003_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H8822	003	0	1	01	01	H8822_003_0	6	2	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	003	0	1	01	01	H8822_003_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H8822	003	0	1	01	01	H8822_003_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8822	004	0	1	01	01	H8822_004_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H8822	004	0	1	01	01	H8822_004_0	6	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H8822	004	0	1	01	01	H8822_004_0	6	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8822	004	0	1	01	01	H8822_004_0	6	2	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	004	0	1	01	01	H8822_004_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010110000000	30	90								30		30								90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00		5.00	10.00								5.00
H8822	004	0	1	01	01	H8822_004_0	6	2	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H8822	004	0	1	01	01	H8822_004_0	6	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00
H8822	004	0	1	01	01	H8822_004_0	6	5	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H8822	004	0	1	01	01	H8822_004_0	6	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00
H8822	004	0	1	01	01	H8822_004_0	6	5	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H8836	001	0	1	08	03	H8836_001_0	7	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00									65.00		130.00								65.00
H8836	001	0	1	08	03	H8836_001_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00									35.00		70.00								35.00
H8836	001	0	1	08	03	H8836_001_0	7	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00
H8836	001	0	1	08	03	H8836_001_0	7	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
H8980	001	0	1	04	01	H8980_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00
H8980	001	0	1	04	01	H8980_001_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																							Tier 3 - Non-Preferred Generic/Non-Preferred Brand			Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand																					
H8980	001	0	1	04	01	H8980_001_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H8980	001	0	1	04	01	H8980_001_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H8980	001	0	1	04	01	H8980_001_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00
H8980	001	0	1	04	01	H8980_001_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
H8980	001	0	1	04	01	H8980_001_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	25.00	50.00								25.00			50.00								25.00
H8980	001	0	1	04	01	H8980_001_0	7	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2			Tier 4 - Specialty Drugs																							Tier 4 - Specialty Drugs			Tier 4 - Specialty Drugs																						Tier 4 - Specialty Drugs																					
H8980	002	0	1	04	01	H8980_002_0	6	4	3	1	Tier 4 - Specialty Drugs	010010		1				Tier 4 - Specialty Drugs	110000000010000000000	30									30											31	Tier 4 - Specialty Drugs	2	1	Tier 4 - Specialty Drugs	30									30											30	Tier 4 - Specialty Drugs																					
H8980	002	0	1	04	01	H8980_002_0	6	3	3	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100		2				Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
H8980	002	0	1	04	01	H8980_002_0	6	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	60.00								30.00			60.00								30.00
H8980	002	0	1	04	01	H8980_002_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	16.00								8.00			16.00								8.00
H8991	011	0	1	01	01	H8991_011_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H8991	011	0	1	01	01	H8991_011_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	011	0	1	01	01	H8991_011_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H8991	011	0	1	01	01	H8991_011_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H8991	012	0	1	01	01	H8991_012_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H8991	012	0	1	01	01	H8991_012_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H8991	012	0	1	01	01	H8991_012_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H8991	012	0	1	01	01	H8991_012_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	012	0	1	01	01	H8991_012_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H8991	012	0	1	01	01	H8991_012_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H8991	012	0	1	01	01	H8991_012_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H8991	012	0	1	01	01	H8991_012_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	017	0	1	01	01	H8991_017_0	7	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																					
H8991	017	0	1	01	01	H8991_017_0	7	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	90.00	180.00	135.00							90.00		90.00	180.00	135.00							90.00
H8991	017	0	1	01	01	H8991_017_0	7	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	017	0	1	01	01	H8991_017_0	7	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	45.00	90.00	67.50							45.00		45.00	90.00	67.50							45.00
H8991	018	0	1	01	01	H8991_018_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	80.00	160.00	120.00							80.00		80.00	160.00	120.00							80.00
H8991	018	0	1	01	01	H8991_018_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	018	0	1	01	01	H8991_018_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H8991	018	0	1	01	01	H8991_018_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H8991	019	0	1	01	01	H8991_019_0	4	2	4	3	Preferred Brand Name Drugs	000001	1	2	2			Preferred Brand Name Drugs																							Preferred Brand Name Drugs			Preferred Brand Name Drugs																						Preferred Brand Name Drugs																					
H8991	019	0	1	01	01	H8991_019_0	4	1	4	3	Generic Drugs	010000	1	2	1		1	Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	019	0	1	01	01	H8991_019_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H8991	019	0	1	01	01	H8991_019_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	30.00	60.00	45.00							30.00		30.00	60.00	45.00							30.00
H8991	019	0	1	01	01	H8991_019_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	5.00	10.00	7.50							5.00		5.00	10.00	7.50							5.00
H8991	019	0	1	01	01	H8991_019_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	019	0	1	01	01	H8991_019_0	4	3	4	3	Non-Preferred Brand Name Drugs	100000	1	2	2			Non-Preferred Brand Name Drugs																							Non-Preferred Brand Name Drugs			Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs																					
H8991	019	0	1	01	01	H8991_019_0	4	4	4	3	Specialty Drugs	010010	1	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
H8991	022	0	1	01	01	H8991_022_0	4	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	022	0	1	01	01	H8991_022_0	4	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	40.00	80.00	60.00							40.00		40.00	80.00	60.00							40.00
H8991	022	0	1	01	01	H8991_022_0	4	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H8991	022	0	1	01	01	H8991_022_0	4	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	10.00	20.00	15.00							10.00		10.00	20.00	15.00							10.00
H8991	027	0	1	01	01	H8991_027_0	5	2	4	1	Preferred Brand Name Drugs	000001	1	2				Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Preferred Brand Name Drugs	2	2	Preferred Brand Name Drugs																						Preferred Brand Name Drugs	20.00	40.00	30.00							20.00		20.00	40.00	30.00							20.00
H8991	027	0	1	01	01	H8991_027_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
H8991	027	0	1	01	01	H8991_027_0	5	3	4	1	Non-Preferred Brand Name Drugs	100000	1	2				Non-Preferred Brand Name Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Non-Preferred Brand Name Drugs	2	2	Non-Preferred Brand Name Drugs																						Non-Preferred Brand Name Drugs	60.00	120.00	90.00							60.00		60.00	120.00	90.00							60.00
H8991	027	0	1	01	01	H8991_027_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111100000010111000000	31	93	62							31		31	62							93	31	Specialty Drugs	2	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																					
H9001	006	0	1	01	01	H9001_006_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00
H9001	006	0	1	01	01	H9001_006_0	7	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00
H9001	006	0	1	01	01	H9001_006_0	7	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00
H9001	011	0	1	01	01	H9001_011_0	7	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00
H9001	011	0	1	01	01	H9001_011_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00
H9001	011	0	1	01	01	H9001_011_0	7	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00
H9001	012	0	1	01	01	H9001_012_0	5	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00
H9001	012	0	1	01	01	H9001_012_0	5	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00
H9001	012	0	1	01	01	H9001_012_0	5	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00
H9001	013	0	1	01	01	H9001_013_0	6	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H9001	013	0	1	01	01	H9001_013_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H9001	013	0	1	01	01	H9001_013_0	6	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00	110.00							55.00		55.00	165.00	110.00							55.00
H9001	014	0	1	01	01	H9001_014_0	7	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00
H9001	014	0	1	01	01	H9001_014_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00
H9001	014	0	1	01	01	H9001_014_0	7	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00
H9001	015	0	1	01	01	H9001_015_0	6	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00	110.00							55.00		55.00	165.00	110.00							55.00
H9001	015	0	1	01	01	H9001_015_0	6	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H9001	015	0	1	01	01	H9001_015_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H9001	017	0	1	01	01	H9001_017_0	6	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
H9001	017	0	1	01	01	H9001_017_0	6	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	165.00	110.00							55.00		55.00	165.00	110.00							55.00
H9001	017	0	1	01	01	H9001_017_0	6	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00
H9001	018	0	1	01	01	H9001_018_0	7	1	4	1	Tier 1	001000	3	2				Tier 1	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00
H9001	018	0	1	01	01	H9001_018_0	7	2	4	1	Tier 2	000101	3	2				Tier 2	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00
H9001	018	0	1	01	01	H9001_018_0	7	3	4	1	Tier 3	100000	3	2				Tier 3	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00
H9003	001	0	1	01	01	H9003_001_0	7	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9003	001	0	1	01	01	H9003_001_0	7	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H9003	001	0	1	01	01	H9003_001_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9003	001	0	1	01	01	H9003_001_0	7	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9003	001	0	1	01	01	H9003_001_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9003	001	0	1	01	01	H9003_001_0	7	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00		45.00	90.00								45.00
H9003	006	0	1	01	01	H9003_006_0	3	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9003	006	0	1	01	01	H9003_006_0	3	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H9003	006	0	1	01	01	H9003_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9003	006	0	1	01	01	H9003_006_0	3	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00		45.00	90.00								45.00
H9003	006	0	1	01	01	H9003_006_0	3	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9003	006	0	1	01	01	H9003_006_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9011	003	0	1	01	01	H9011_003_0	5	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
H9011	003	0	1	01	01	H9011_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9011	003	0	1	01	01	H9011_003_0	5	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00						0.00			0.00		0.00
H9011	003	0	1	01	01	H9011_003_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H9011	003	0	1	01	01	H9011_003_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	35.00	105.00								35.00						95.00			105.00		35.00
H9011	003	0	1	01	01	H9011_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00						20.00			30.00		10.00
H9011	003	0	1	01	01	H9011_003_0	5	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9011	003	0	1	01	01	H9011_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00						0.00			0.00		0.00
H9011	016	0	1	02	01	H9011_016_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00						8.00			12.00		4.00
H9011	016	0	1	02	01	H9011_016_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00						35.00			45.00		15.00
H9011	016	0	1	02	01	H9011_016_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	40.00	120.00								40.00						110.00			120.00		40.00
H9011	016	0	1	02	01	H9011_016_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H9047	001	0	1	01	01	H9047_001_0	6	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Generic	2	2	Generic																						Generic				4.00	12.00		7.00	21.00		7.00					4.00	12.00		7.00	21.00		7.00
H9047	001	0	1	01	01	H9047_001_0	6	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Brand	2	2	Brand																						Brand				40.00	120.00		40.00	120.00		40.00					40.00	120.00		40.00	120.00		40.00
H9047	001	0	1	01	01	H9047_001_0	6	3	4	1	Speciality	010010	1	1				Speciality	100010010010000100100				30			30			30				30			30				34	Speciality	2	1	Speciality				33			33			33					33			33			33	Speciality																					
H9047	013	0	2	01	01	H9047_013_0	6	3	4	1	Speciality	010010	1	1				Speciality	100010010010000100100				30			30			30				30			30				34	Speciality	2	1	Speciality				33			33			33					33			33			33	Speciality																					
H9047	013	0	2	01	01	H9047_013_0	6	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Generic	2	2	Generic																						Generic				4.00	12.00		7.00	21.00		7.00					4.00	12.00		7.00	21.00		7.00
H9047	013	0	2	01	01	H9047_013_0	6	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Brand	2	2	Brand																						Brand				40.00	120.00		40.00	120.00		40.00					40.00	120.00		40.00	120.00		40.00
H9047	024	0	1	02	01	H9047_024_0	7	2	4	1	Brand	000010	1	2				Brand	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Brand	2	2	Brand																						Brand				40.00	120.00		40.00	120.00		40.00					40.00	120.00		40.00	120.00		40.00
H9047	024	0	1	02	01	H9047_024_0	7	3	4	1	Speciality	010010	1	1				Speciality	100010010010000100100				30			30			30				30			30				34	Speciality	2	1	Speciality				33			33			33					33			33			33	Speciality																					
H9047	024	0	1	02	01	H9047_024_0	7	1	4	1	Generic	010000	1	2				Generic	100011011010000110110				30	90		30	90		30				30	90		30	90			34	Generic	2	2	Generic																						Generic				4.00	12.00		7.00	21.00		7.00					4.00	12.00		7.00	21.00		7.00
H9082	001	0	1	01	01	H9082_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00
H9082	001	0	1	01	01	H9082_001_0	5	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
H9082	001	0	1	01	01	H9082_001_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																					
H9082	001	0	1	01	01	H9082_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H9082	002	0	1	01	01	H9082_002_0	5	3	4	1	Non-Preferred Brand	000100	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
H9082	002	0	1	01	01	H9082_002_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00
H9082	002	0	1	01	01	H9082_002_0	5	4	4	1	Specialty Drugs	010010	1	1				Specialty Drugs	111000000010010000000	31	90								31										90	31	Specialty Drugs	2	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																					
H9082	002	0	1	01	01	H9082_002_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00
H9101	007	0	1	01	01	H9101_007_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H9101	007	0	1	01	01	H9101_007_0	7	2	4	1	Preferred	000001	1	2				Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H9101	007	0	1	01	01	H9101_007_0	7	3	4	1	Brand	100000	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00
H9101	007	0	1	01	01	H9101_007_0	7	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9101	007	0	1	01	01	H9101_007_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
H9101	007	0	1	01	01	H9101_007_0	7	2	4	3	Preferred	000001	1	2	1		1	Preferred	111000000010010000000	30	90								30										90	31	Preferred	2	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00
H9101	007	0	1	01	01	H9101_007_0	7	3	4	3	Brand	100000	1	2	2			Brand																							Brand			Brand																						Brand																					
H9101	007	0	1	01	01	H9101_007_0	7	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
H9103	001	0	1	01	01	H9103_001_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9103	001	0	1	01	01	H9103_001_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00
H9103	001	0	1	01	01	H9103_001_0	4	3	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9103	001	0	1	01	01	H9103_001_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00
H9103	001	0	1	01	01	H9103_001_0	4	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H9103	001	0	1	01	01	H9103_001_0	4	3	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9104	006	0	1	01	01	H9104_006_0	11	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9104	006	0	1	01	01	H9104_006_0	11	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H9104	006	0	1	01	01	H9104_006_0	11	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H9104	006	0	1	01	01	H9104_006_0	11	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H9104	006	0	1	01	01	H9104_006_0	11	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	006	0	1	01	01	H9104_006_0	11	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9104	006	0	1	01	01	H9104_006_0	11	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H9104	006	0	1	01	01	H9104_006_0	11	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H9104	006	0	1	01	01	H9104_006_0	11	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H9104	006	0	1	01	01	H9104_006_0	11	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	007	0	1	01	01	H9104_007_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	007	0	1	01	01	H9104_007_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9104	007	0	1	01	01	H9104_007_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H9104	007	0	1	01	01	H9104_007_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H9104	007	0	1	01	01	H9104_007_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H9104	007	0	1	01	01	H9104_007_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	007	0	1	01	01	H9104_007_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9104	007	0	1	01	01	H9104_007_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H9104	007	0	1	01	01	H9104_007_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H9104	007	0	1	01	01	H9104_007_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00
H9104	008	0	1	01	01	H9104_008_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	008	0	1	01	01	H9104_008_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9104	008	0	1	01	01	H9104_008_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H9104	008	0	1	01	01	H9104_008_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H9104	008	0	1	01	01	H9104_008_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H9104	008	0	1	01	01	H9104_008_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	008	0	1	01	01	H9104_008_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9104	008	0	1	01	01	H9104_008_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H9104	008	0	1	01	01	H9104_008_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H9104	008	0	1	01	01	H9104_008_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H9104	009	0	1	01	01	H9104_009_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9104	009	0	1	01	01	H9104_009_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00
H9104	009	0	1	01	01	H9104_009_0	10	3	4	1	Brand	000001	3	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00
H9104	009	0	1	01	01	H9104_009_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H9104	009	0	1	01	01	H9104_009_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	009	0	1	01	01	H9104_009_0	10	2	4	3	Preferred Generic	010000	3	2	1		1	Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			20.00								10.00
H9104	009	0	1	01	01	H9104_009_0	10	3	4	3	Brand	000001	3	2	2			Brand																							Brand			Brand																						Brand																					
H9104	009	0	1	01	01	H9104_009_0	10	1	4	3	Select Generic	001000	1	2	1		1	Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	009	0	1	01	01	H9104_009_0	10	5	4	3	Specialty	001001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9104	009	0	1	01	01	H9104_009_0	10	4	4	3	Additional Brand	000001	1	2	2			Additional Brand																							Additional Brand			Additional Brand																						Additional Brand																					
H9104	013	0	1	01	01	H9104_013_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H9104	013	0	1	01	01	H9104_013_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H9104	013	0	1	01	01	H9104_013_0	10	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H9104	013	0	1	01	01	H9104_013_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H9104	013	0	1	01	01	H9104_013_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	014	0	1	01	01	H9104_014_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9104	014	0	1	01	01	H9104_014_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H9104	014	0	1	01	01	H9104_014_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H9104	014	0	1	01	01	H9104_014_0	10	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H9104	014	0	1	01	01	H9104_014_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H9104	015	0	1	01	01	H9104_015_0	10	4	4	1	Additional Brand	000001	1	2				Additional Brand	111000000010010000000	31	90								31										90	31	Additional Brand	2	2	Additional Brand																						Additional Brand	0.00	0.00								0.00			0.00								0.00
H9104	015	0	1	01	01	H9104_015_0	10	5	4	1	Specialty	001001	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	2	Specialty																						Specialty	0.00									0.00											0.00
H9104	015	0	1	01	01	H9104_015_0	10	3	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00
H9104	015	0	1	01	01	H9104_015_0	10	2	4	1	Preferred Generic	010000	3	2				Preferred Generic	111000000010010000000	31	90								31										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00
H9104	015	0	1	01	01	H9104_015_0	10	1	4	1	Select Generic	001000	1	2				Select Generic	111000000010010000000	31	90								31										90	31	Select Generic	2	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00
H9149	002	0	1	02	01	H9149_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
H9149	002	0	1	02	01	H9149_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
H9149	002	0	1	02	01	H9149_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
H9149	002	0	1	02	01	H9149_002_0	4	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
H9302	001	0	1	01	01	H9302_001_0	5	3	4	1	Tier III	100000	3	2				Tier III	111000000001110000000	30	90									10	30								90	31	Tier III	2	2	Tier III																						Tier III	50.00	100.00									50.00	50.00	100.00								50.00
H9302	001	0	1	01	01	H9302_001_0	5	2	4	1	Tier II	000001	3	2				Tier II	111000000001110000000	30	90									10	30								90	31	Tier II	2	2	Tier II																						Tier II	25.00	50.00									25.00	25.00	50.00								25.00
H9302	001	0	1	01	01	H9302_001_0	5	1	4	1	Tier I	001000	3	2				Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	001	0	1	01	01	H9302_001_0	5	4	4	1	Tier IV	010010	1	1				Tier IV	111000000001110000000	30	90									10	30								90	31	Tier IV	2	1	Tier IV	10	10									10	10	10								10	Tier IV																					
H9302	001	0	1	01	01	H9302_001_0	5	1	4	3	Tier I	001000	3	2	1		1	Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	001	0	1	01	01	H9302_001_0	5	2	4	3	Tier II	000001	3	2	2			Tier II																							Tier II			Tier II																						Tier II																					
H9302	001	0	1	01	01	H9302_001_0	5	3	4	3	Tier III	100000	3	2	2			Tier III																							Tier III			Tier III																						Tier III																					
H9302	001	0	1	01	01	H9302_001_0	5	4	4	3	Tier IV	010010	1	1	2			Tier IV																							Tier IV			Tier IV																						Tier IV																					
H9302	003	0	1	01	01	H9302_003_0	5	3	4	1	Tier III	100000	3	2				Tier III	111000000001110000000	30	90									10	30								90	31	Tier III	2	2	Tier III																						Tier III	50.00	100.00									50.00	50.00	100.00								50.00
H9302	003	0	1	01	01	H9302_003_0	5	2	4	1	Tier II	000001	3	2				Tier II	111000000001110000000	30	90									10	30								90	31	Tier II	2	2	Tier II																						Tier II	25.00	50.00									25.00	25.00	50.00								25.00
H9302	003	0	1	01	01	H9302_003_0	5	1	4	1	Tier I	001000	3	2				Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	003	0	1	01	01	H9302_003_0	5	4	4	1	Tier IV	010010	3	1				Tier IV	111000000001110000000	30	90									10	30								90	31	Tier IV	2	1	Tier IV	10	10									10	10	10								10	Tier IV																					
H9302	005	0	1	01	01	H9302_005_0	5	1	4	1	Tier I	001000	3	2				Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	005	0	1	01	01	H9302_005_0	5	2	4	1	Tier II	000001	3	2				Tier II	111000000001110000000	30	90									10	30								90	31	Tier II	2	2	Tier II																						Tier II	25.00	50.00									25.00	25.00	50.00								25.00
H9302	005	0	1	01	01	H9302_005_0	5	3	4	1	Tier III	100000	3	2				Tier III	111000000001110000000	30	90									10	30								90	31	Tier III	2	2	Tier III																						Tier III	50.00	100.00									50.00	50.00	100.00								50.00
H9302	005	0	1	01	01	H9302_005_0	5	4	4	1	Tier IV	010010	1	1				Tier IV	111000000001110000000	30	90									10	30								90	31	Tier IV	2	1	Tier IV	10	10									10	10	10								10	Tier IV																					
H9302	005	0	1	01	01	H9302_005_0	5	1	4	3	Tier I	001000	3	2	1		1	Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	005	0	1	01	01	H9302_005_0	5	2	4	3	Tier II	000001	3	2	2			Tier II																							Tier II			Tier II																						Tier II																					
H9302	005	0	1	01	01	H9302_005_0	5	4	4	3	Tier IV	010010	1	1	2			Tier IV																							Tier IV			Tier IV																						Tier IV																					
H9302	005	0	1	01	01	H9302_005_0	5	3	4	3	Tier III	100000	3	2	2			Tier III																							Tier III			Tier III																						Tier III																					
H9302	007	0	1	01	01	H9302_007_0	5	1	2	1	Tier I	001000		2				Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	6.00	12.00									6.00	6.00	12.00								6.00
H9302	007	0	1	01	01	H9302_007_0	5	3	2	1	Tier III	101101		1				Tier III	111000000001110000000	30	90									10	30								90	31	Tier III	2	1	Tier III	25	25									25	25	25								25	Tier III																					
H9302	007	0	1	01	01	H9302_007_0	5	2	2	1	Tier II	000001		2				Tier II	111000000001110000000	30	90									10	30								90	31	Tier II	2	2	Tier II																						Tier II	25.00	50.00									25.00	25.00	50.00								25.00
H9302	007	0	1	01	01	H9302_007_0	5	4	2	1	Tier IV	100000		2				Tier IV	111000000001110000000	30	90									10	30								90	31	Tier IV	2	2	Tier IV																						Tier IV	50.00	100.00									50.00	50.00	100.00								50.00
H9302	008	0	1	02	01	H9302_008_0	7	1	4	1	Tier I	001000	3	2				Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	008	0	1	02	01	H9302_008_0	7	2	4	1	Tier II	000001	3	2				Tier II	111000000001110000000	30	90									10	30								90	31	Tier II	2	2	Tier II																						Tier II	25.00	50.00									25.00	25.00	50.00								25.00
H9302	008	0	1	02	01	H9302_008_0	7	3	4	1	Tier III	100000	3	2				Tier III	111000000001110000000	30	90									10	30								90	31	Tier III	2	2	Tier III																						Tier III	50.00	100.00									50.00	50.00	100.00								50.00
H9302	008	0	1	02	01	H9302_008_0	7	4	4	1	Tier IV	010010	3	1				Tier IV	111000000001110000000	30	90									10	30								90	31	Tier IV	2	1	Tier IV	10	10									10	10	10								10	Tier IV																					
H9302	008	0	1	02	01	H9302_008_0	7	1	4	3	Tier I	001000	3	2	1		1	Tier I	111000000001110000000	30	90									10	30								90	31	Tier I	2	2	Tier I																						Tier I	5.00	10.00									5.00	5.00	10.00								5.00
H9302	008	0	1	02	01	H9302_008_0	7	2	4	3	Tier II	000001	3	2	2			Tier II																							Tier II			Tier II																						Tier II																					
H9302	008	0	1	02	01	H9302_008_0	7	3	4	3	Tier III	100000	3	2	2			Tier III																							Tier III			Tier III																						Tier III																					
H9302	008	0	1	02	01	H9302_008_0	7	4	4	3	Tier IV	010010	3	1	2			Tier IV																							Tier IV			Tier IV																						Tier IV																					
H9313	007	0	1	02	01	H9313_007_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	007	0	1	02	01	H9313_007_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	007	0	1	02	01	H9313_007_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	007	0	1	02	01	H9313_007_0	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	010	1	1	01	01	H9313_010_1	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	010	1	1	01	01	H9313_010_1	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	010	1	1	01	01	H9313_010_1	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	010	1	1	01	01	H9313_010_1	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	010	2	1	01	01	H9313_010_2	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	010	2	1	01	01	H9313_010_2	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	010	2	1	01	01	H9313_010_2	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	010	2	1	01	01	H9313_010_2	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	011	1	1	02	01	H9313_011_1	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	011	1	1	02	01	H9313_011_1	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	011	1	1	02	01	H9313_011_1	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	011	1	1	02	01	H9313_011_1	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	011	1	1	02	01	H9313_011_1	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9313	011	1	1	02	01	H9313_011_1	4	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9313	011	1	1	02	01	H9313_011_1	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9313	011	1	1	02	01	H9313_011_1	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	011	2	1	02	01	H9313_011_2	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9313	011	2	1	02	01	H9313_011_2	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9313	011	2	1	02	01	H9313_011_2	4	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9313	011	2	1	02	01	H9313_011_2	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	011	2	1	02	01	H9313_011_2	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	011	2	1	02	01	H9313_011_2	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	011	2	1	02	01	H9313_011_2	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	011	2	1	02	01	H9313_011_2	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	012	1	1	02	01	H9313_012_1	5	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9313	012	1	1	02	01	H9313_012_1	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	012	1	1	02	01	H9313_012_1	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	012	1	1	02	01	H9313_012_1	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9313	012	1	1	02	01	H9313_012_1	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9313	012	1	1	02	01	H9313_012_1	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	012	1	1	02	01	H9313_012_1	5	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	012	1	1	02	01	H9313_012_1	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	012	2	1	02	01	H9313_012_2	5	4	4	3	Specialty	110001	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9313	012	2	1	02	01	H9313_012_2	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9313	012	2	1	02	01	H9313_012_2	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9313	012	2	1	02	01	H9313_012_2	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	92.00	276.00								92.00			230.00								92.00
H9313	012	2	1	02	01	H9313_012_2	5	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
H9313	012	2	1	02	01	H9313_012_2	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9313	012	2	1	02	01	H9313_012_2	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00			105.00								42.00
H9313	012	2	1	02	01	H9313_012_2	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
H9385	002	0	1	01	01	H9385_002_0	7	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	31									31											31	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9385	002	0	1	01	01	H9385_002_0	7	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	31	90								31										90	31	Brand	2	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00
H9385	002	0	1	01	01	H9385_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H9385	002	0	1	01	01	H9385_002_0	7	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
H9385	002	0	1	01	01	H9385_002_0	7	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
H9385	002	0	1	01	01	H9385_002_0	7	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9452	002	0	1	09	04	H9452_002_0	9	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H9452	002	0	1	09	04	H9452_002_0	9	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H9452	002	0	1	09	04	H9452_002_0	9	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H9452	002	0	1	09	04	H9452_002_0	9	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H9452	002	0	1	09	04	H9452_002_0	9	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H9452	002	0	1	09	04	H9452_002_0	9	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H9452	002	0	1	09	04	H9452_002_0	9	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H9452	002	0	1	09	04	H9452_002_0	9	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H9452	002	0	1	09	04	H9452_002_0	9	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H9452	002	0	1	09	04	H9452_002_0	9	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H9466	001	0	1	01	01	H9466_001_0	8	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H9466	001	0	1	01	01	H9466_001_0	8	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
H9466	001	0	1	01	01	H9466_001_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
H9466	001	0	1	01	01	H9466_001_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
H9466	001	0	1	01	01	H9466_001_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
H9466	001	0	1	01	01	H9466_001_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
H9466	001	0	1	01	01	H9466_001_0	8	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
H9466	001	0	1	01	01	H9466_001_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
H9466	001	0	1	01	01	H9466_001_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
H9466	001	0	1	01	01	H9466_001_0	8	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
H9503	001	0	1	04	01	H9503_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H9503	001	0	1	04	01	H9503_001_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H9503	001	0	1	04	01	H9503_001_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H9503	001	0	1	04	01	H9503_001_0	7	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H9503	001	0	1	04	01	H9503_001_0	7	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
H9503	001	0	1	04	01	H9503_001_0	7	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00
H9503	001	0	1	04	01	H9503_001_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
H9503	001	0	1	04	01	H9503_001_0	7	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
H9519	001	0	1	09	04	H9519_001_0	10	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00								40.00											40.00
H9519	001	0	1	09	04	H9519_001_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00			62.50								25.00
H9519	001	0	1	09	04	H9519_001_0	10	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H9519	001	0	1	09	04	H9519_001_0	10	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	25									25											25	Specialty Tier 4																					
H9519	001	0	1	09	04	H9519_001_0	10	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H9519	001	0	1	09	04	H9519_001_0	10	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H9519	001	0	1	09	04	H9519_001_0	10	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H9519	001	0	1	09	04	H9519_001_0	10	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00
H9519	003	0	1	09	04	H9519_003_0	10	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H9519	003	0	1	09	04	H9519_003_0	10	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	34	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00
H9519	003	0	1	09	04	H9519_003_0	10	3	4	1	Tier 3	100100	1	2				Tier 3	111000000010000000000	30	90								30											34	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00											70.00
H9519	003	0	1	09	04	H9519_003_0	10	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H9519	003	0	1	09	04	H9519_003_0	10	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H9519	003	0	1	09	04	H9519_003_0	10	1	4	3	Tier 1	001001	1	2	1	10001000	2	Tier 1	111000000010010000000	30	90								30										90	34	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00
H9519	003	0	1	09	04	H9519_003_0	10	4	4	1	Specialty Tier 4	001001	1	1				Specialty Tier 4	110000000010000000000	30									30											34	Specialty Tier 4	2	1	Specialty Tier 4	33									33											33	Specialty Tier 4																					
H9519	003	0	1	09	04	H9519_003_0	10	4	4	3	Specialty Tier 4	001001	1	1	2			Specialty Tier 4																							Specialty Tier 4			Specialty Tier 4																						Specialty Tier 4																					
H9615	002	0	1	04	01	H9615_002_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9615	002	0	1	04	01	H9615_002_0	8	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H9615	002	0	1	04	01	H9615_002_0	8	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H9615	002	0	1	04	01	H9615_002_0	8	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9615	002	0	1	04	01	H9615_002_0	8	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H9615	002	0	1	04	01	H9615_002_0	8	3	4	3	Tier 3	010010	1	1	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H9615	004	0	1	04	01	H9615_004_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9615	004	0	1	04	01	H9615_004_0	9	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H9615	004	0	1	04	01	H9615_004_0	9	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H9615	004	0	1	04	01	H9615_004_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9615	004	0	1	04	01	H9615_004_0	9	2	4	3	Tier 2	000010	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
H9615	004	0	1	04	01	H9615_004_0	9	3	4	3	Tier 3	010010	1	1	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
H9663	001	0	1	04	01	H9663_001_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00
H9663	001	0	1	04	01	H9663_001_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
H9663	001	0	1	04	01	H9663_001_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					48.00			72.00		24.00
H9663	001	0	1	04	01	H9663_001_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
H9663	001	0	1	04	01	H9663_001_0	6	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
H9663	002	0	1	04	01	H9663_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
H9663	002	0	1	04	01	H9663_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H9663	002	0	1	04	01	H9663_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
H9663	002	0	1	04	01	H9663_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
H9663	002	0	1	04	01	H9663_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
H9663	002	0	1	04	01	H9663_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00
H9663	002	0	1	04	01	H9663_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00
H9663	002	0	1	04	01	H9663_002_0	5	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
H9663	002	0	1	04	01	H9663_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
H9663	002	0	1	04	01	H9663_002_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
H9670	001	0	1	04	01	H9670_001_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H9670	001	0	1	04	01	H9670_001_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H9670	001	0	1	04	01	H9670_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H9670	001	0	1	04	01	H9670_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H9670	001	0	1	04	01	H9670_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H9670	001	0	1	04	01	H9670_001_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9670	001	0	1	04	01	H9670_001_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9670	001	0	1	04	01	H9670_001_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9670	002	0	1	04	01	H9670_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9670	002	0	1	04	01	H9670_002_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H9670	002	0	1	04	01	H9670_002_0	6	4	4	1	Specialty	010010	1	1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
H9670	002	0	1	04	01	H9670_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00			187.50								75.00
H9670	002	0	1	04	01	H9670_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			62.50								25.00
H9670	002	0	1	04	01	H9670_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
H9670	002	0	1	04	01	H9670_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9670	002	0	1	04	01	H9670_002_0	6	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9720	009	0	1	09	04	H9720_009_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H9720	009	0	1	09	04	H9720_009_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		42.00	126.00								42.00
H9720	009	0	1	09	04	H9720_009_0	11	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H9720	009	0	1	09	04	H9720_009_0	11	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	72.00	216.00								72.00		72.00	216.00								72.00
H9720	011	0	1	09	04	H9720_011_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
H9720	011	0	1	09	04	H9720_011_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
H9720	011	0	1	09	04	H9720_011_0	9	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	65.00	195.00								65.00		65.00	195.00								65.00
H9720	011	0	1	09	04	H9720_011_0	9	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H9720	026	0	1	09	04	H9720_026_0	11	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
H9720	026	0	1	09	04	H9720_026_0	11	3	4	1	Brand	000010	1	2				Brand	111000000010110000000	30	90								30		30								90	31	Brand	2	2	Brand																						Brand	58.00	174.00								58.00		58.00	174.00								58.00
H9720	026	0	1	09	04	H9720_026_0	11	4	4	1	Specialty	100000	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
H9720	026	0	1	09	04	H9720_026_0	11	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00		28.00	84.00								28.00
H9793	001	0	1	09	04	H9793_001_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9793	001	0	1	09	04	H9793_001_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H9793	001	0	1	09	04	H9793_001_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H9793	001	0	1	09	04	H9793_001_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H9793	003	0	1	09	04	H9793_003_0	9	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H9793	003	0	1	09	04	H9793_003_0	9	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00		72.50	72.50								29.00
H9793	003	0	1	09	04	H9793_003_0	9	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H9793	003	0	1	09	04	H9793_003_0	9	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9793	003	0	1	09	04	H9793_003_0	9	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H9793	003	0	1	09	04	H9793_003_0	9	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9793	003	0	1	09	04	H9793_003_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9793	003	0	1	09	04	H9793_003_0	9	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9793	004	0	1	09	04	H9793_004_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
H9793	004	0	1	09	04	H9793_004_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9793	004	0	1	09	04	H9793_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	198.00								66.00		165.00	165.00								66.00
H9793	004	0	1	09	04	H9793_004_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00		90.00	90.00								36.00
H9793	006	0	1	09	04	H9793_006_0	8	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9793	006	0	1	09	04	H9793_006_0	8	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9793	006	0	1	09	04	H9793_006_0	8	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H9793	006	0	1	09	04	H9793_006_0	8	4	4	1	Specialty	010010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
H9793	006	0	1	09	04	H9793_006_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		150.00	150.00								60.00
H9793	006	0	1	09	04	H9793_006_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00		72.50	72.50								29.00
H9793	006	0	1	09	04	H9793_006_0	8	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
H9793	006	0	1	09	04	H9793_006_0	8	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9847	001	0	1	04	01	H9847_001_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9847	001	0	1	04	01	H9847_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
H9847	001	0	1	04	01	H9847_001_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H9847	001	0	1	04	01	H9847_001_0	5	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
H9847	001	0	1	04	01	H9847_001_0	5	3	4	3	Non-preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-preferred Generic/Non-Preferred Brand																							Non-preferred Generic/Non-Preferred Brand			Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand																					
H9847	001	0	1	04	01	H9847_001_0	5	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2				Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Generic/Non-Preferred Brand	2	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
H9847	001	0	1	04	01	H9847_001_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
H9847	001	0	1	04	01	H9847_001_0	5	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	30									30											30	Specialty-Generic and Brand																					
H9859	002	0	1	01	01	H9859_002_0	10	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9859	002	0	1	01	01	H9859_002_0	10	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H9859	002	0	1	01	01	H9859_002_0	10	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H9859	004	0	1	01	01	H9859_004_0	8	2	4	1	Tier 2	000010	1	2				Tier 2	111000000010110000000	34	90								34		34								90	34	Tier 2	1	2	Tier 2																						Tier 2	40.00	120.00								40.00		80.00	80.00								40.00
H9859	004	0	1	01	01	H9859_004_0	8	3	4	1	Tier 3	010010	1	1				Tier 3	111000000010110000000	34	90								34		34								90	34	Tier 3	2	1	Tier 3	25	25								25		25	25								25	Tier 3																					
H9859	004	0	1	01	01	H9859_004_0	8	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010110000000	34	90								34		34								90	34	Tier 1	1	2	Tier 1																						Tier 1	5.00	15.00								5.00		10.00	10.00								5.00
H9882	001	0	1	01	01	H9882_001_0	5	4	4	1	Specialty	000010	1	1				Specialty	110000000010100000000	34									34		34									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H9882	001	0	1	01	01	H9882_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	110000000010100000000	34									34		34									34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	94.00									94.00		94.00									94.00
H9882	001	0	1	01	01	H9882_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	110000000010100000000	34									34		34									34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	46.50									46.50		46.50									46.50
H9882	001	0	1	01	01	H9882_001_0	5	1	4	1	Generic	010000	1	2				Generic	110000000010100000000	34									34		34									34	Generic	2	2	Generic																						Generic	0.00									0.00		0.00									0.00
H9882	002	0	1	01	01	H9882_002_0	6	1	4	1	Generic	010000	1	2				Generic	110000000010100000000	34									34		34									34	Generic	2	2	Generic																						Generic	0.00									0.00		0.00									0.00
H9882	002	0	1	01	01	H9882_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	110000000010100000000	34									34		34									34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	46.50									46.50		46.50									46.50
H9882	002	0	1	01	01	H9882_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	110000000010100000000	34									34		34									34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	94.00									94.00		94.00									94.00
H9882	002	0	1	01	01	H9882_002_0	6	4	4	1	Specialty	000010	1	1				Specialty	110000000010100000000	34									34		34									34	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
H9930	003	0	1	04	01	H9930_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
H9930	003	0	1	04	01	H9930_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	30									30											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
H9930	003	0	1	04	01	H9930_003_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H9930	003	0	1	04	01	H9930_003_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
H9930	003	0	1	04	01	H9930_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
H9930	003	0	1	04	01	H9930_003_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
H9930	003	0	1	04	01	H9930_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
H9930	003	0	1	04	01	H9930_003_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
H9931	001	0	1	09	04	H9931_001_0	6	2	3	1	Formulary Brand	000010		2				Formulary Brand	111000000010110000000	30	90								30		30								90	31	Formulary Brand	2	2	Formulary Brand																						Formulary Brand	34.00	102.00								34.00		34.00	68.00								34.00
H9931	001	0	1	09	04	H9931_001_0	6	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	8.00	24.00								8.00		8.00	16.00								8.00
H9931	001	0	1	09	04	H9931_001_0	6	3	3	1	Formulary Specialty	000010		1				Formulary Specialty	110000000010100000000	30									30		30									31	Formulary Specialty	2	1	Formulary Specialty	25									25		25									25	Formulary Specialty																					
R3175	001	0	1	31	11	R3175_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R3175	001	0	1	31	11	R3175_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
R3175	001	0	1	31	11	R3175_001_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
R3175	001	0	1	31	11	R3175_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R3175	004	0	1	31	11	R3175_004_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R3175	004	0	1	31	11	R3175_004_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
R3175	004	0	1	31	11	R3175_004_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
R3175	004	0	1	31	11	R3175_004_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R3444	001	0	1	31	11	R3444_001_0	11	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	001	0	1	31	11	R3444_001_0	11	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	42.00	126.00								42.00		42.00	126.00								42.00
R3444	001	0	1	31	11	R3444_001_0	11	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00		0.00	0.00								0.00
R3444	001	0	1	31	11	R3444_001_0	11	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	002	0	1	31	11	R3444_002_0	9	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	002	0	1	31	11	R3444_002_0	9	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	002	0	1	31	11	R3444_002_0	9	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R3444	002	0	1	31	11	R3444_002_0	9	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	003	0	1	31	11	R3444_003_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	003	0	1	31	11	R3444_003_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	003	0	1	31	11	R3444_003_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	003	0	1	31	11	R3444_003_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	34.00	102.00								34.00		34.00	102.00								34.00
R3444	004	0	1	31	11	R3444_004_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	004	0	1	31	11	R3444_004_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R3444	004	0	1	31	11	R3444_004_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	004	0	1	31	11	R3444_004_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	005	0	1	31	11	R3444_005_0	8	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R3444	005	0	1	31	11	R3444_005_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	005	0	1	31	11	R3444_005_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R3444	005	0	1	31	11	R3444_005_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	005	0	1	31	11	R3444_005_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	005	0	1	31	11	R3444_005_0	8	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R3444	005	0	1	31	11	R3444_005_0	8	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R3444	005	0	1	31	11	R3444_005_0	8	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R3444	005	0	1	31	11	R3444_005_0	8	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R3444	005	0	1	31	11	R3444_005_0	8	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R3444	006	0	1	31	11	R3444_006_0	8	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R3444	006	0	1	31	11	R3444_006_0	8	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R3444	006	0	1	31	11	R3444_006_0	8	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R3444	006	0	1	31	11	R3444_006_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R3444	006	0	1	31	11	R3444_006_0	8	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R3444	006	0	1	31	11	R3444_006_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	006	0	1	31	11	R3444_006_0	8	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R3444	006	0	1	31	11	R3444_006_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	006	0	1	31	11	R3444_006_0	8	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R3444	006	0	1	31	11	R3444_006_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	34.00	102.00								34.00		34.00	102.00								34.00
R3444	007	0	1	31	11	R3444_007_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R3444	007	0	1	31	11	R3444_007_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	34.00	102.00								34.00		34.00	102.00								34.00
R3444	007	0	1	31	11	R3444_007_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R3444	007	0	1	31	11	R3444_007_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R5287	001	0	1	31	11	R5287_001_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
R5287	001	0	1	31	11	R5287_001_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R5287	001	0	1	31	11	R5287_001_0	6	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R5287	001	0	1	31	11	R5287_001_0	6	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
R5342	001	0	1	31	11	R5342_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
R5342	001	0	1	31	11	R5342_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R5342	001	0	1	31	11	R5342_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
R5342	001	0	1	31	11	R5342_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R5342	004	0	1	31	11	R5342_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R5342	004	0	1	31	11	R5342_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00
R5342	004	0	1	31	11	R5342_004_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R5342	004	0	1	31	11	R5342_004_0	5	3	4	1	Non Preferred	100100	1	2				Non Preferred	111000000010000010010	31	90								31					90			90			31	Non Preferred	2	2	Non Preferred																						Non Preferred	71.00	213.00								71.00						203.00			213.00		71.00
R5566	005	0	1	31	11	R5566_005_0	6	4	2	1	Covered Specialty	110011		1				Covered Specialty	111000000010010000000	31	90								31										90	31	Covered Specialty	2	1	Covered Specialty	25	25								25			25								25	Covered Specialty																					
R5566	005	0	1	31	11	R5566_005_0	6	2	2	1	Level 2: Covered Preferred Brand	000001		2				Level 2: Covered Preferred Brand	111000000010010000000	31	90								31										90	31	Level 2: Covered Preferred Brand	2	1	Level 2: Covered Preferred Brand	19	19								19			19								19	Level 2: Covered Preferred Brand																					
R5566	005	0	1	31	11	R5566_005_0	6	3	2	1	Level 3: Covered Brand	100000		2				Level 3: Covered Brand	111000000010010000000	31	90								31										90	31	Level 3: Covered Brand	2	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																					
R5566	005	0	1	31	11	R5566_005_0	6	1	2	1	Level 1: Covered Generic	010000		2				Level 1: Covered Generic	111000000010010000000	31	90								31										90	31	Level 1: Covered Generic	2	1	Level 1: Covered Generic	10	10								10			10								10	Level 1: Covered Generic																					
R5595	001	0	1	31	11	R5595_001_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
R5595	001	0	1	31	11	R5595_001_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
R5595	001	0	1	31	11	R5595_001_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
R5595	001	0	1	31	11	R5595_001_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				24.00	60.00		24.00	72.00			24.00					48.00			72.00		24.00
R5595	001	0	1	31	11	R5595_001_0	8	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
R5595	003	0	1	31	11	R5595_003_0	9	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				4.00	10.00		4.00	12.00			4.00					8.00			12.00		4.00
R5595	003	0	1	31	11	R5595_003_0	9	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					52.00			78.00		26.00
R5595	003	0	1	31	11	R5595_003_0	9	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
R5595	003	0	1	31	11	R5595_003_0	9	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
R5595	003	0	1	31	11	R5595_003_0	9	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
R5595	004	0	1	31	11	R5595_004_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
R5595	004	0	1	31	11	R5595_004_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
R5595	004	0	1	31	11	R5595_004_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
R5595	004	0	1	31	11	R5595_004_0	8	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
R5595	004	0	1	31	11	R5595_004_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
R5595	004	0	1	31	11	R5595_004_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
R5595	004	0	1	31	11	R5595_004_0	8	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
R5595	004	0	1	31	11	R5595_004_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
R5595	004	0	1	31	11	R5595_004_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
R5595	004	0	1	31	11	R5595_004_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
R5595	006	0	1	31	11	R5595_006_0	10	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
R5595	006	0	1	31	11	R5595_006_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				6.00	15.00		6.00	18.00			6.00					12.00			18.00		6.00
R5595	006	0	1	31	11	R5595_006_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				33.00	82.50		33.00	99.00			33.00					66.00			99.00		33.00
R5595	006	0	1	31	11	R5595_006_0	10	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
R5595	006	0	1	31	11	R5595_006_0	10	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
R5595	006	0	1	31	11	R5595_006_0	10	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
R5595	006	0	1	31	11	R5595_006_0	10	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
R5595	006	0	1	31	11	R5595_006_0	10	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
R5595	006	0	1	31	11	R5595_006_0	10	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
R5595	006	0	1	31	11	R5595_006_0	10	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
R5595	007	0	1	31	11	R5595_007_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
R5595	007	0	1	31	11	R5595_007_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
R5595	007	0	1	31	11	R5595_007_0	8	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
R5595	007	0	1	31	11	R5595_007_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
R5595	007	0	1	31	11	R5595_007_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
R5595	007	0	1	31	11	R5595_007_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				75.00	187.50		75.00	225.00			75.00					150.00			225.00		75.00
R5595	007	0	1	31	11	R5595_007_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					70.00			105.00		35.00
R5595	007	0	1	31	11	R5595_007_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
R5595	007	0	1	31	11	R5595_007_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
R5595	007	0	1	31	11	R5595_007_0	8	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
R5674	001	0	1	31	11	R5674_001_0	12	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	40.00	90.00								40.00			80.00								40.00
R5674	001	0	1	31	11	R5674_001_0	12	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00
R5674	001	0	1	31	11	R5674_001_0	12	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
R5826	001	0	1	31	11	R5826_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	001	0	1	31	11	R5826_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	001	0	1	31	11	R5826_001_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	001	0	1	31	11	R5826_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	001	0	1	31	11	R5826_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	001	0	1	31	11	R5826_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	001	0	1	31	11	R5826_001_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	001	0	1	31	11	R5826_001_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	002	0	1	31	11	R5826_002_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	002	0	1	31	11	R5826_002_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	002	0	1	31	11	R5826_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	002	0	1	31	11	R5826_002_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	002	0	1	31	11	R5826_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	002	0	1	31	11	R5826_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	002	0	1	31	11	R5826_002_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	002	0	1	31	11	R5826_002_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	003	0	1	31	11	R5826_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	003	0	1	31	11	R5826_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	003	0	1	31	11	R5826_003_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	003	0	1	31	11	R5826_003_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	003	0	1	31	11	R5826_003_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	003	0	1	31	11	R5826_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	003	0	1	31	11	R5826_003_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	003	0	1	31	11	R5826_003_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	004	0	1	31	11	R5826_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	004	0	1	31	11	R5826_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	004	0	1	31	11	R5826_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	004	0	1	31	11	R5826_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	004	0	1	31	11	R5826_004_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	004	0	1	31	11	R5826_004_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	004	0	1	31	11	R5826_004_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	004	0	1	31	11	R5826_004_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	005	0	1	31	11	R5826_005_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
R5826	005	0	1	31	11	R5826_005_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	005	0	1	31	11	R5826_005_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	005	0	1	31	11	R5826_005_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	005	0	1	31	11	R5826_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
R5826	005	0	1	31	11	R5826_005_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	005	0	1	31	11	R5826_005_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	005	0	1	31	11	R5826_005_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	006	0	1	31	11	R5826_006_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	006	0	1	31	11	R5826_006_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	006	0	1	31	11	R5826_006_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	006	0	1	31	11	R5826_006_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	006	0	1	31	11	R5826_006_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	006	0	1	31	11	R5826_006_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	006	0	1	31	11	R5826_006_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	006	0	1	31	11	R5826_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	007	0	1	31	11	R5826_007_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	007	0	1	31	11	R5826_007_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	007	0	1	31	11	R5826_007_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	007	0	1	31	11	R5826_007_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	007	0	1	31	11	R5826_007_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	007	0	1	31	11	R5826_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	007	0	1	31	11	R5826_007_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	007	0	1	31	11	R5826_007_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	008	0	1	31	11	R5826_008_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	008	0	1	31	11	R5826_008_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	008	0	1	31	11	R5826_008_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	008	0	1	31	11	R5826_008_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	008	0	1	31	11	R5826_008_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	008	0	1	31	11	R5826_008_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	008	0	1	31	11	R5826_008_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	008	0	1	31	11	R5826_008_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	009	0	1	31	11	R5826_009_0	8	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	009	0	1	31	11	R5826_009_0	8	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
R5826	009	0	1	31	11	R5826_009_0	8	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	009	0	1	31	11	R5826_009_0	8	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
R5826	009	0	1	31	11	R5826_009_0	8	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	009	0	1	31	11	R5826_009_0	8	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	63.00	189.00								63.00					63.00	157.50		63.00	189.00		63.00
R5826	009	0	1	31	11	R5826_009_0	8	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	009	0	1	31	11	R5826_009_0	8	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00
R5826	010	0	1	31	11	R5826_010_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	010	0	1	31	11	R5826_010_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	010	0	1	31	11	R5826_010_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	010	0	1	31	11	R5826_010_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	010	0	1	31	11	R5826_010_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	010	0	1	31	11	R5826_010_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	010	0	1	31	11	R5826_010_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	010	0	1	31	11	R5826_010_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	011	0	1	31	11	R5826_011_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	011	0	1	31	11	R5826_011_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	011	0	1	31	11	R5826_011_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	011	0	1	31	11	R5826_011_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	011	0	1	31	11	R5826_011_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	011	0	1	31	11	R5826_011_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	011	0	1	31	11	R5826_011_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	011	0	1	31	11	R5826_011_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	012	0	1	31	11	R5826_012_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	012	0	1	31	11	R5826_012_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	012	0	1	31	11	R5826_012_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	012	0	1	31	11	R5826_012_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	012	0	1	31	11	R5826_012_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	012	0	1	31	11	R5826_012_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	012	0	1	31	11	R5826_012_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	012	0	1	31	11	R5826_012_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	013	0	1	31	11	R5826_013_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	013	0	1	31	11	R5826_013_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	013	0	1	31	11	R5826_013_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	013	0	1	31	11	R5826_013_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	013	0	1	31	11	R5826_013_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	013	0	1	31	11	R5826_013_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	013	0	1	31	11	R5826_013_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	013	0	1	31	11	R5826_013_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	014	0	1	31	11	R5826_014_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	014	0	1	31	11	R5826_014_0	6	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	014	0	1	31	11	R5826_014_0	6	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	014	0	1	31	11	R5826_014_0	6	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	014	0	1	31	11	R5826_014_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	014	0	1	31	11	R5826_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	014	0	1	31	11	R5826_014_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	014	0	1	31	11	R5826_014_0	6	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	049	0	1	31	11	R5826_049_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	049	0	1	31	11	R5826_049_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	049	0	1	31	11	R5826_049_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	049	0	1	31	11	R5826_049_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	049	0	1	31	11	R5826_049_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	049	0	1	31	11	R5826_049_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	049	0	1	31	11	R5826_049_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	049	0	1	31	11	R5826_049_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	051	0	1	31	11	R5826_051_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	051	0	1	31	11	R5826_051_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	051	0	1	31	11	R5826_051_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	051	0	1	31	11	R5826_051_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
R5826	051	0	1	31	11	R5826_051_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	051	0	1	31	11	R5826_051_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	051	0	1	31	11	R5826_051_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00
R5826	051	0	1	31	11	R5826_051_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	054	0	1	31	11	R5826_054_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	054	0	1	31	11	R5826_054_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	054	0	1	31	11	R5826_054_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	054	0	1	31	11	R5826_054_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	054	0	1	31	11	R5826_054_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	054	0	1	31	11	R5826_054_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	054	0	1	31	11	R5826_054_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	054	0	1	31	11	R5826_054_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	059	0	1	31	11	R5826_059_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	059	0	1	31	11	R5826_059_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	059	0	1	31	11	R5826_059_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	059	0	1	31	11	R5826_059_0	5	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5826	059	0	1	31	11	R5826_059_0	5	1	4	3	Preferred Generic	001000	1	2	1	00001000	2	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
R5826	059	0	1	31	11	R5826_059_0	5	2	4	3	Preferred Brand	000001	1	2	1	10000000	2	Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
R5826	059	0	1	31	11	R5826_059_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	10000000	2	Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00
R5826	059	0	1	31	11	R5826_059_0	5	4	4	3	Specialty	100100	1	1	1	10001000	2	Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
R5863	001	0	1	31	11	R5863_001_0	11	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
R5863	001	0	1	31	11	R5863_001_0	11	2	4	1	Preferrred Brand	000001	1	2				Preferrred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferrred Brand	1	2	Preferrred Brand																						Preferrred Brand	41.00	123.00	82.00							41.00						82.00	82.00	41.00	123.00	82.00	41.00
R5863	001	0	1	31	11	R5863_001_0	11	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
R5863	001	0	1	31	11	R5863_001_0	11	4	4	1	Injectable	010010	1	2				Injectable	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Injectable	1	1	Injectable	33	33	33							33						33	33	33	33	33	33	Injectable																					
R5863	001	0	1	31	11	R5863_001_0	11	5	4	1	Specialty	010010	1	1				Specialty	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Specialty	2	1	Specialty	33	33	33							33						33	33	33	33	33	33	Specialty																					
R5941	001	0	1	31	11	R5941_001_0	10	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	001	0	1	31	11	R5941_001_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
R5941	001	0	1	31	11	R5941_001_0	10	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
R5941	001	0	1	31	11	R5941_001_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
R5941	001	0	1	31	11	R5941_001_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
R5941	001	0	1	31	11	R5941_001_0	10	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	001	0	1	31	11	R5941_001_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
R5941	001	0	1	31	11	R5941_001_0	10	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
R5941	001	0	1	31	11	R5941_001_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
R5941	001	0	1	31	11	R5941_001_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
R5941	002	0	1	31	11	R5941_002_0	10	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	002	0	1	31	11	R5941_002_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
R5941	002	0	1	31	11	R5941_002_0	10	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
R5941	002	0	1	31	11	R5941_002_0	10	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
R5941	002	0	1	31	11	R5941_002_0	10	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
R5941	002	0	1	31	11	R5941_002_0	10	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
R5941	002	0	1	31	11	R5941_002_0	10	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	002	0	1	31	11	R5941_002_0	10	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
R5941	002	0	1	31	11	R5941_002_0	10	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
R5941	002	0	1	31	11	R5941_002_0	10	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
R5941	003	0	1	31	11	R5941_003_0	7	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
R5941	003	0	1	31	11	R5941_003_0	7	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	003	0	1	31	11	R5941_003_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
R5941	003	0	1	31	11	R5941_003_0	7	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
R5941	003	0	1	31	11	R5941_003_0	7	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
R5941	003	0	1	31	11	R5941_003_0	7	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
R5941	003	0	1	31	11	R5941_003_0	7	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	003	0	1	31	11	R5941_003_0	7	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
R5941	003	0	1	31	11	R5941_003_0	7	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
R5941	003	0	1	31	11	R5941_003_0	7	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
R5941	004	0	1	31	11	R5941_004_0	8	1	4	3	Tier One Preferred Generics	001000	3	2	1		1	Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	004	0	1	31	11	R5941_004_0	8	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
R5941	004	0	1	31	11	R5941_004_0	8	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
R5941	004	0	1	31	11	R5941_004_0	8	4	4	3	Tier 4 Non-Specialty Injectibles	010010	1	2	2			Tier 4 Non-Specialty Injectibles																							Tier 4 Non-Specialty Injectibles			Tier 4 Non-Specialty Injectibles																						Tier 4 Non-Specialty Injectibles																					
R5941	004	0	1	31	11	R5941_004_0	8	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
R5941	004	0	1	31	11	R5941_004_0	8	1	4	1	Tier One Preferred Generics	001000	3	2				Tier One Preferred Generics	111000000010000010010	30	90								30					90			90			34	Tier One Preferred Generics	2	2	Tier One Preferred Generics																						Tier One Preferred Generics	10.00	30.00								10.00						15.00			30.00		10.00
R5941	004	0	1	31	11	R5941_004_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
R5941	004	0	1	31	11	R5941_004_0	8	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
R5941	004	0	1	31	11	R5941_004_0	8	4	4	1	Tier 4 Non-Specialty Injectibles	010010	1	2				Tier 4 Non-Specialty Injectibles	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectibles	2	1	Tier 4 Non-Specialty Injectibles	33	33								33						33			33		33	Tier 4 Non-Specialty Injectibles																					
R5941	004	0	1	31	11	R5941_004_0	8	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
R6801	001	0	1	31	11	R6801_001_0	11	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00		0.00	0.00								0.00
R6801	001	0	1	31	11	R6801_001_0	11	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	42.00	126.00								42.00		42.00	126.00								42.00
R6801	001	0	1	31	11	R6801_001_0	11	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	001	0	1	31	11	R6801_001_0	11	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	002	0	1	31	11	R6801_002_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	002	0	1	31	11	R6801_002_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R6801	002	0	1	31	11	R6801_002_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	002	0	1	31	11	R6801_002_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	003	0	1	31	11	R6801_003_0	9	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	003	0	1	31	11	R6801_003_0	9	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R6801	003	0	1	31	11	R6801_003_0	9	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	003	0	1	31	11	R6801_003_0	9	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	004	0	1	31	11	R6801_004_0	9	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	004	0	1	31	11	R6801_004_0	9	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R6801	004	0	1	31	11	R6801_004_0	9	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	004	0	1	31	11	R6801_004_0	9	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	005	0	1	31	11	R6801_005_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	005	0	1	31	11	R6801_005_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R6801	005	0	1	31	11	R6801_005_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	005	0	1	31	11	R6801_005_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	005	0	1	31	11	R6801_005_0	8	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R6801	005	0	1	31	11	R6801_005_0	8	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R6801	005	0	1	31	11	R6801_005_0	8	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R6801	005	0	1	31	11	R6801_005_0	8	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R6801	005	0	1	31	11	R6801_005_0	8	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R6801	005	0	1	31	11	R6801_005_0	8	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R6801	006	0	1	31	11	R6801_006_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	006	0	1	31	11	R6801_006_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R6801	006	0	1	31	11	R6801_006_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	006	0	1	31	11	R6801_006_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R6801	006	0	1	31	11	R6801_006_0	8	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R6801	006	0	1	31	11	R6801_006_0	8	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R6801	006	0	1	31	11	R6801_006_0	8	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R6801	006	0	1	31	11	R6801_006_0	8	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R6801	006	0	1	31	11	R6801_006_0	8	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R6801	006	0	1	31	11	R6801_006_0	8	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R6801	007	0	1	31	11	R6801_007_0	8	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R6801	007	0	1	31	11	R6801_007_0	8	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R6801	007	0	1	31	11	R6801_007_0	8	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R6801	007	0	1	31	11	R6801_007_0	8	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R7444	001	0	1	31	11	R7444_001_0	5	3	4	1	Non-Preferred	100100	1	2				Non-Preferred	111000000010000010010	31	90								31					90			90			31	Non-Preferred	2	2	Non-Preferred																						Non-Preferred	65.00	195.00								65.00						185.00			195.00		65.00
R7444	001	0	1	31	11	R7444_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000010010	31	90								31					90			90			31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00
R7444	001	0	1	31	11	R7444_001_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000010010	31	90								31					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00						10.00			15.00		5.00
R7444	001	0	1	31	11	R7444_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010000010010	31	90								31					90			90			31	Specialty	2	1	Specialty	33	33								33						33			33		33	Specialty																					
R9896	001	0	1	31	11	R9896_001_0	11	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	001	0	1	31	11	R9896_001_0	11	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	001	0	1	31	11	R9896_001_0	11	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00		0.00	0.00								0.00
R9896	001	0	1	31	11	R9896_001_0	11	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	42.00	126.00								42.00		42.00	126.00								42.00
R9896	002	0	1	31	11	R9896_002_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	002	0	1	31	11	R9896_002_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9896	002	0	1	31	11	R9896_002_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R9896	002	0	1	31	11	R9896_002_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	003	0	1	31	11	R9896_003_0	8	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	003	0	1	31	11	R9896_003_0	8	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	003	0	1	31	11	R9896_003_0	8	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9896	003	0	1	31	11	R9896_003_0	8	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R9896	004	0	1	31	11	R9896_004_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9896	004	0	1	31	11	R9896_004_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R9896	004	0	1	31	11	R9896_004_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	004	0	1	31	11	R9896_004_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	005	0	1	31	11	R9896_005_0	9	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R9896	005	0	1	31	11	R9896_005_0	9	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9896	005	0	1	31	11	R9896_005_0	9	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	108.00								36.00
R9896	005	0	1	31	11	R9896_005_0	9	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	005	0	1	31	11	R9896_005_0	9	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	005	0	1	31	11	R9896_005_0	9	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R9896	005	0	1	31	11	R9896_005_0	9	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R9896	005	0	1	31	11	R9896_005_0	9	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R9896	005	0	1	31	11	R9896_005_0	9	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R9896	005	0	1	31	11	R9896_005_0	9	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R9896	006	0	1	31	11	R9896_006_0	8	4	4	3	Formulary Specialty	010010	1	1	2			Formulary Specialty																							Formulary Specialty			Formulary Specialty																						Formulary Specialty																					
R9896	006	0	1	31	11	R9896_006_0	8	3	4	3	Formulary Non-Preferred Brand	100000	1	2	2			Formulary Non-Preferred Brand																							Formulary Non-Preferred Brand			Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																					
R9896	006	0	1	31	11	R9896_006_0	8	2	4	3	Formulary Preferred Brand	000001	1	2	2			Formulary Preferred Brand																							Formulary Preferred Brand			Formulary Preferred Brand																						Formulary Preferred Brand																					
R9896	006	0	1	31	11	R9896_006_0	8	1	4	3	Formulary Generic	010000	1	2	2			Formulary Generic																							Formulary Generic			Formulary Generic																						Formulary Generic																					
R9896	006	0	1	31	11	R9896_006_0	8	5	4	1	Formulary Zero Copay	010010	1	2				Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R9896	006	0	1	31	11	R9896_006_0	8	4	4	1	Formulary Specialty	010010	1	1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	006	0	1	31	11	R9896_006_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	006	0	1	31	11	R9896_006_0	8	2	4	1	Formulary Preferred Brand	000001	1	2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R9896	006	0	1	31	11	R9896_006_0	8	1	4	1	Formulary Generic	010000	1	2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9896	006	0	1	31	11	R9896_006_0	8	5	4	3	Formulary Zero Copay	010010	1	2	1		1	Formulary Zero Copay	111000000010110000000	30	90								30		30								90	31	Formulary Zero Copay	2	2	Formulary Zero Copay																						Formulary Zero Copay	0.00	0.00								0.00		0.00	0.00								0.00
R9896	007	0	1	31	11	R9896_007_0	8	2	3	1	Formulary Preferred Brand	000001		2				Formulary Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Preferred Brand	2	2	Formulary Preferred Brand																						Formulary Preferred Brand	33.00	99.00								33.00		33.00	99.00								33.00
R9896	007	0	1	31	11	R9896_007_0	8	3	3	1	Formulary Non-Preferred Brand	100000		2				Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Formulary Non-Preferred Brand	2	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00
R9896	007	0	1	31	11	R9896_007_0	8	4	3	1	Formulary Specialty	010010		1				Formulary Specialty	111000000010110000000	30	90								30		30								90	31	Formulary Specialty	2	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																					
R9896	007	0	1	31	11	R9896_007_0	8	1	3	1	Formulary Generic	010000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	27.00								9.00
R9943	001	0	1	31	11	R9943_001_0	14	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
R9943	001	0	1	31	11	R9943_001_0	14	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
R9943	001	0	1	31	11	R9943_001_0	14	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
R9943	001	0	1	31	11	R9943_001_0	14	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
R9943	001	0	1	31	11	R9943_001_0	14	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
R9943	001	0	1	31	11	R9943_001_0	14	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
R9943	001	0	1	31	11	R9943_001_0	14	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
R9943	001	0	1	31	11	R9943_001_0	14	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
R9943	001	0	1	31	11	R9943_001_0	14	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
R9943	001	0	1	31	11	R9943_001_0	14	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S0043	009	0		29	10	S0043_009_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
S0043	009	0		29	10	S0043_009_0	2	2	2	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
S0043	009	0		29	10	S0043_009_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00
S0043	009	0		29	10	S0043_009_0	2	4	2	1	Specialty	010011		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S0043	010	0		29	10	S0043_010_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00
S0043	010	0		29	10	S0043_010_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
S0043	010	0		29	10	S0043_010_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
S0043	010	0		29	10	S0043_010_0	4	4	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S0043	013	0		29	10	S0043_013_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00
S0043	013	0		29	10	S0043_013_0	5	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00
S0043	013	0		29	10	S0043_013_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00
S0043	013	0		29	10	S0043_013_0	5	4	4	3	Specialty	010011	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S0043	013	0		29	10	S0043_013_0	5	4	4	1	Specialty	010011	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S0043	013	0		29	10	S0043_013_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00
S0043	013	0		29	10	S0043_013_0	5	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S0043	013	0		29	10	S0043_013_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S0197	002	0		29	10	S0197_002_0	2	4	4	1	Speciality-Generic and Brand	010010	1	1				Speciality-Generic and Brand	110000000010000000000	30									30											31	Speciality-Generic and Brand	2	1	Speciality-Generic and Brand	33									33											33	Speciality-Generic and Brand																					
S0197	002	0		29	10	S0197_002_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S0197	002	0		29	10	S0197_002_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S0197	002	0		29	10	S0197_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S0197	003	0		29	10	S0197_003_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S0197	003	0		29	10	S0197_003_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S0197	003	0		29	10	S0197_003_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
S0197	003	0		29	10	S0197_003_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S0197	005	0		29	10	S0197_005_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S0197	005	0		29	10	S0197_005_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S0197	005	0		29	10	S0197_005_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S0197	005	0		29	10	S0197_005_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S0197	005	0		29	10	S0197_005_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S0197	005	0		29	10	S0197_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S0197	005	0		29	10	S0197_005_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S0197	005	0		29	10	S0197_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S1030	001	0		29	10	S1030_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00
S1030	001	0		29	10	S1030_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
S1030	001	0		29	10	S1030_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
S1030	001	0		29	10	S1030_001_0	5	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
S1030	006	0		29	10	S1030_006_0	4	1	3	1	Generic	010000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S1030	006	0		29	10	S1030_006_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00
S1030	006	0		29	10	S1030_006_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00
S1030	006	0		29	10	S1030_006_0	4	4	3	1	Specialty	000010		1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S2321	002	0		29	10	S2321_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00
S2321	002	0		29	10	S2321_002_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
S2321	002	0		29	10	S2321_002_0	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S2321	002	0		29	10	S2321_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00
S2468	001	0		29	10	S2468_001_0	4	1	4	1	Formulary Generic	001000	3	2				Formulary Generic	100011011010010000000				30	90		30	90		30										90	34	Formulary Generic	2	2	Formulary Generic																						Formulary Generic				10.00	20.00		10.00	30.00		10.00			20.00								10.00
S2468	001	0		29	10	S2468_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011011010010000000				30	90		30	90		30										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand				60.00	120.00		60.00	180.00		60.00			120.00								60.00
S2468	001	0		29	10	S2468_001_0	4	4	4	1	Injectables	001001	1	2				Injectables	100011011010010000000				30	90		30	90		30										90	34	Injectables	2	1	Injectables				25	25		25	25		25			25								25	Injectables																					
S2468	001	0		29	10	S2468_001_0	4	5	4	1	Formulary Specialty (Unique High Cost Drugs)	001001	1	1				Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30										90	34	Formulary Specialty (Unique High Cost Drugs)	2	1	Formulary Specialty (Unique High Cost Drugs)				25	25		25	25		25			25								25	Formulary Specialty (Unique High Cost Drugs)																					
S2468	001	0		29	10	S2468_001_0	4	2	4	1	Formulary Brand	000001	1	2				Formulary Brand	100011011010010000000				30	90		30	90		30										90	34	Formulary Brand	2	2	Formulary Brand																						Formulary Brand				30.00	60.00		30.00	90.00		30.00			60.00								30.00
S2505	001	0		29	10	S2505_001_0	4	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	25.00									25.00		25.00									25.00
S2505	001	0		29	10	S2505_001_0	4	3	3	1	Tier 3 - NonPreferred Brand, NonPreferred Generic	100100		2				Tier 3 - NonPreferred Brand, NonPreferred Generic	110000000010100000000	30									30		30									31	Tier 3 - NonPreferred Brand, NonPreferred Generic	2	2	Tier 3 - NonPreferred Brand, NonPreferred Generic																						Tier 3 - NonPreferred Brand, NonPreferred Generic	50.00									50.00		50.00									50.00
S2505	001	0		29	10	S2505_001_0	4	4	3	1	Tier 4 - Speciality (Brand or Generic)	010010		1				Tier 4 - Speciality (Brand or Generic)	110000000010100000000	30									30		30									31	Tier 4 - Speciality (Brand or Generic)	2	1	Tier 4 - Speciality (Brand or Generic)	25									25		25									25	Tier 4 - Speciality (Brand or Generic)																					
S2505	001	0		29	10	S2505_001_0	4	1	3	1	Tier 1 - Preferred Generics	001000		2				Tier 1 - Preferred Generics	110000000010100000000	30									30		30									31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	10.00									10.00		10.00									10.00
S2505	003	0		29	10	S2505_003_0	4	3	3	1	Tier 3 - NonPreferred Brand, NonPreferred Generic	100100		2				Tier 3 - NonPreferred Brand, NonPreferred Generic	110000000010100000000	30									30		30									31	Tier 3 - NonPreferred Brand, NonPreferred Generic	2	2	Tier 3 - NonPreferred Brand, NonPreferred Generic																						Tier 3 - NonPreferred Brand, NonPreferred Generic	50.00									50.00		50.00									50.00
S2505	003	0		29	10	S2505_003_0	4	4	3	1	Tier 4 - Speciality (Brand or Generic)	010010		1				Tier 4 - Speciality (Brand or Generic)	110000000010100000000	30									30		30									31	Tier 4 - Speciality (Brand or Generic)	2	1	Tier 4 - Speciality (Brand or Generic)	25									25		25									25	Tier 4 - Speciality (Brand or Generic)																					
S2505	003	0		29	10	S2505_003_0	4	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	25.00									25.00		25.00									25.00
S2505	003	0		29	10	S2505_003_0	4	1	3	1	Tier 1 - Preferred Generics	001000		2				Tier 1 - Preferred Generics	110000000010100000000	30									30		30									31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	10.00									10.00		10.00									10.00
S2505	005	0		29	10	S2505_005_0	5	4	3	1	Tier 4 - Speciality (Brand or Generic)	010010		1				Tier 4 - Speciality (Brand or Generic)	110000000010100000000	30									30		30									31	Tier 4 - Speciality (Brand or Generic)	2	1	Tier 4 - Speciality (Brand or Generic)	25									25		25									25	Tier 4 - Speciality (Brand or Generic)																					
S2505	005	0		29	10	S2505_005_0	5	1	3	1	Tier 1 - Preferred Generics	001000		2				Tier 1 - Preferred Generics	110000000010100000000	30									30		30									31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	10.00									10.00		10.00									10.00
S2505	005	0		29	10	S2505_005_0	5	3	3	1	Tier 3 - NonPreferred Brand, NonPreferred Generic	100100		2				Tier 3 - NonPreferred Brand, NonPreferred Generic	110000000010100000000	30									30		30									31	Tier 3 - NonPreferred Brand, NonPreferred Generic	2	2	Tier 3 - NonPreferred Brand, NonPreferred Generic																						Tier 3 - NonPreferred Brand, NonPreferred Generic	50.00									50.00		50.00									50.00
S2505	005	0		29	10	S2505_005_0	5	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	25.00									25.00		25.00									25.00
S2505	007	0		29	10	S2505_007_0	5	3	3	1	Tier 3 - NonPreferred Brand, NonPreferred Generic	100100		2				Tier 3 - NonPreferred Brand, NonPreferred Generic	110000000010100000000	30									30		30									31	Tier 3 - NonPreferred Brand, NonPreferred Generic	2	2	Tier 3 - NonPreferred Brand, NonPreferred Generic																						Tier 3 - NonPreferred Brand, NonPreferred Generic	50.00									50.00		50.00									50.00
S2505	007	0		29	10	S2505_007_0	5	1	3	1	Tier 1 - Preferred Generics	001000		2				Tier 1 - Preferred Generics	110000000010100000000	30									30		30									31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	10.00									10.00		10.00									10.00
S2505	007	0		29	10	S2505_007_0	5	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	25.00									25.00		25.00									25.00
S2505	007	0		29	10	S2505_007_0	5	4	3	1	Tier 4 - Speciality (Brand or Generic)	010010		1				Tier 4 - Speciality (Brand or Generic)	110000000010100000000	30									30		30									31	Tier 4 - Speciality (Brand or Generic)	2	1	Tier 4 - Speciality (Brand or Generic)	25									25		25									25	Tier 4 - Speciality (Brand or Generic)																					
S2873	002	0		29	10	S2873_002_0	3	4	4	1	Specialty-Tier 4	010010	1	1				Specialty-Tier 4	111000000001110000000	31	90									10	31								90	31	Specialty-Tier 4	2	1	Specialty-Tier 4	33	33									33	33	33								33	Specialty-Tier 4																					
S2873	002	0		29	10	S2873_002_0	3	3	4	1	Non-preferred Brand-Tier 3	100000	1	2				Non-preferred Brand-Tier 3	111000000001110000000	31	90									10	31								90	31	Non-preferred Brand-Tier 3	2	2	Non-preferred Brand-Tier 3																						Non-preferred Brand-Tier 3	50.00	150.00									50.00	50.00	100.00								50.00
S2873	002	0		29	10	S2873_002_0	3	2	4	1	Preferred Brand-Tier 2	000001	1	2				Preferred Brand-Tier 2	111000000001110000000	31	90									10	31								90	31	Preferred Brand-Tier 2	2	2	Preferred Brand-Tier 2																						Preferred Brand-Tier 2	30.00	90.00									30.00	30.00	60.00								30.00
S2873	002	0		29	10	S2873_002_0	3	1	4	1	Generic-Tier 1	010000	1	2				Generic-Tier 1	111000000001110000000	31	90									10	31								90	31	Generic-Tier 1	2	2	Generic-Tier 1																						Generic-Tier 1	5.00	15.00									5.00	5.00	10.00								5.00
S2873	003	0		29	10	S2873_003_0	4	4	4	3	Specialty-Tier 4	010010	1	1	2			Specialty-Tier 4																							Specialty-Tier 4			Specialty-Tier 4																						Specialty-Tier 4																					
S2873	003	0		29	10	S2873_003_0	4	3	4	3	Non-preferred Brand-Tier 3	100000	1	2	2			Non-preferred Brand-Tier 3																							Non-preferred Brand-Tier 3			Non-preferred Brand-Tier 3																						Non-preferred Brand-Tier 3																					
S2873	003	0		29	10	S2873_003_0	4	3	4	1	Non-preferred Brand-Tier 3	100000	1	2				Non-preferred Brand-Tier 3	111000000001110000000	31	90									10	31								90	31	Non-preferred Brand-Tier 3	2	2	Non-preferred Brand-Tier 3																						Non-preferred Brand-Tier 3	45.00	135.00									45.00	45.00	90.00								45.00
S2873	003	0		29	10	S2873_003_0	4	1	4	3	Generic-Tier 1	010000	1	2	1		1	Generic-Tier 1	111000000001110000000	31	90									10	31								90	31	Generic-Tier 1	2	2	Generic-Tier 1																						Generic-Tier 1	2.00	6.00									2.00	2.00	6.00								2.00
S2873	003	0		29	10	S2873_003_0	4	2	4	3	Preferred Brand-Tier 2	000001	1	2	2			Preferred Brand-Tier 2																							Preferred Brand-Tier 2			Preferred Brand-Tier 2																						Preferred Brand-Tier 2																					
S2873	003	0		29	10	S2873_003_0	4	4	4	1	Specialty-Tier 4	010010	1	1				Specialty-Tier 4	111000000001110000000	31	90									10	31								90	31	Specialty-Tier 4	2	1	Specialty-Tier 4	33	33									33	33	33								33	Specialty-Tier 4																					
S2873	003	0		29	10	S2873_003_0	4	1	4	1	Generic-Tier 1	010000	1	2				Generic-Tier 1	111000000001110000000	31	90									10	31								90	31	Generic-Tier 1	2	2	Generic-Tier 1																						Generic-Tier 1	2.00	6.00									2.00	2.00	4.00								2.00
S2873	003	0		29	10	S2873_003_0	4	2	4	1	Preferred Brand-Tier 2	000001	1	2				Preferred Brand-Tier 2	111000000001110000000	31	90									10	31								90	31	Preferred Brand-Tier 2	2	2	Preferred Brand-Tier 2																						Preferred Brand-Tier 2	25.00	75.00									25.00	25.00	50.00								25.00
S2874	001	0		29	10	S2874_001_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S2874	001	0		29	10	S2874_001_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S2874	001	0		29	10	S2874_001_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S2874	002	0		29	10	S2874_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S2874	002	0		29	10	S2874_002_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S2874	002	0		29	10	S2874_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S2874	002	0		29	10	S2874_002_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S2893	001	0		29	10	S2893_001_0	2	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	30.00	90.00								30.00			75.00								30.00
S2893	001	0		29	10	S2893_001_0	2	3	4	1	Tier 3 Non-Preferred Brand	100000	1	2				Tier 3 Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	65.00	195.00								65.00			162.50								65.00
S2893	001	0		29	10	S2893_001_0	2	4	4	1	Tier 4 Specialty	010010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
S2893	001	0		29	10	S2893_001_0	2	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00			20.00								8.00
S2893	003	0		29	10	S2893_003_0	2	3	4	1	Tier 3 Non-Preferred Brand	100000	1	2				Tier 3 Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00
S2893	003	0		29	10	S2893_003_0	2	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	24.00	72.00								24.00			60.00								24.00
S2893	003	0		29	10	S2893_003_0	2	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00			20.00								8.00
S2893	003	0		29	10	S2893_003_0	2	4	4	1	Tier 4 Specialty	010010	1	1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																					
S2893	003	0		29	10	S2893_003_0	2	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00			20.00								8.00
S2893	003	0		29	10	S2893_003_0	2	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S2893	003	0		29	10	S2893_003_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2			Tier 4 Specialty																							Tier 4 Specialty			Tier 4 Specialty																						Tier 4 Specialty																					
S2893	003	0		29	10	S2893_003_0	2	3	4	3	Tier 3 Non-Preferred Brand	100000	1	2	2			Tier 3 Non-Preferred Brand																							Tier 3 Non-Preferred Brand			Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand																					
S2893	014	0		29	10	S2893_014_0	2	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00			20.00								8.00
S2893	014	0		29	10	S2893_014_0	2	2	2	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	24.00	72.00								24.00			60.00								24.00
S2893	014	0		29	10	S2893_014_0	2	3	2	1	Tier 3 Non-Preferred Brand	100000		2				Tier 3 Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Non-Preferred Brand	2	2	Tier 3 Non-Preferred Brand																						Tier 3 Non-Preferred Brand	63.00	189.00								63.00			157.50								63.00
S2893	014	0		29	10	S2893_014_0	2	4	2	1	Tier 4 Specialty	010010		1				Tier 4 Specialty	111000000010010000000	30	90								30										90	31	Tier 4 Specialty	2	1	Tier 4 Specialty	25	25								25			25								25	Tier 4 Specialty																					
S3389	005	0		29	10	S3389_005_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S3389	005	0		29	10	S3389_005_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00
S3389	005	0		29	10	S3389_005_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
S3389	005	0		29	10	S3389_005_0	4	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
S3440	001	0		29	10	S3440_001_0	7	4	3	1	Tier 4	100001		1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	60.00	150.00								60.00			150.00								60.00
S3440	001	0		29	10	S3440_001_0	7	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	60.00	150.00								60.00			150.00								60.00
S3440	001	0		29	10	S3440_001_0	7	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	100.00								40.00			100.00								40.00
S3440	001	0		29	10	S3440_001_0	7	1	3	1	Tier 1	001000		2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	8.00	20.00								8.00			20.00								8.00
S3440	002	0		29	10	S3440_002_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
S3440	002	0		29	10	S3440_002_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00
S3440	002	0		29	10	S3440_002_0	6	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
S3440	002	0		29	10	S3440_002_0	6	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	2.00	5.00								2.00			5.00								2.00
S3440	002	0		29	10	S3440_002_0	6	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S3440	002	0		29	10	S3440_002_0	6	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
S3440	002	0		29	10	S3440_002_0	6	4	4	3	Tier 4	100001	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S3440	002	0		29	10	S3440_002_0	6	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S3440	003	0		29	10	S3440_003_0	5	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	30	90								30										90	31	Tier 3	2	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00
S3440	003	0		29	10	S3440_003_0	5	4	4	1	Tier 4	100001	1	1				Tier 4	111000000010010000000	30	90								30										90	31	Tier 4	2	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00
S3440	003	0		29	10	S3440_003_0	5	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	30	90								30										90	31	Tier 2	2	2	Tier 2																						Tier 2	17.00	50.00								17.00			50.00								17.00
S3440	003	0		29	10	S3440_003_0	5	1	4	1	Tier 1	001001	1	2				Tier 1	111000000010010000000	30	90								30										90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	7.50								3.00			7.50								3.00
S3521	003	0		29	10	S3521_003_0	4	1	4	1	Generics	010000	3	2				Generics	111000000010010000000	30	90								30										90	31	Generics	1	2	Generics																						Generics	5.00	12.50								5.00			12.50								5.00
S3521	003	0		29	10	S3521_003_0	4	2	4	1	Preferred Brand	000001	3	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00			75.00								30.00
S3521	003	0		29	10	S3521_003_0	4	3	4	1	Non-Preferred Brand	100000	3	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00
S3521	003	0		29	10	S3521_003_0	4	4	4	1	Specialty	000010	3	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S4496	001	0		29	10	S4496_001_0	1	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
S4496	001	0		29	10	S4496_001_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
S4496	001	0		29	10	S4496_001_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	88.00	264.00								88.00			264.00								88.00
S4496	001	0		29	10	S4496_001_0	1	4	2	1	Specialty	110001		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S4496	003	0		29	10	S4496_003_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			14.00								7.00
S4496	003	0		29	10	S4496_003_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00			74.00								37.00
S4496	003	0		29	10	S4496_003_0	1	3	4	1	Non-preferred Brand	100000	1	2				Non-preferred Brand	111000000010010000000	30	90								30										90	31	Non-preferred Brand	2	2	Non-preferred Brand																						Non-preferred Brand	70.00	210.00								70.00			140.00								70.00
S4496	003	0		29	10	S4496_003_0	1	4	4	1	Specialty	110001	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S4802	001	0		29	10	S4802_001_0	5	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	001	0		29	10	S4802_001_0	5	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	001	0		29	10	S4802_001_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	001	0		29	10	S4802_001_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	002	0		29	10	S4802_002_0	5	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	002	0		29	10	S4802_002_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	002	0		29	10	S4802_002_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	002	0		29	10	S4802_002_0	5	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	003	0		29	10	S4802_003_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	003	0		29	10	S4802_003_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	003	0		29	10	S4802_003_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	003	0		29	10	S4802_003_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	004	0		29	10	S4802_004_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	004	0		29	10	S4802_004_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	004	0		29	10	S4802_004_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	004	0		29	10	S4802_004_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	005	0		29	10	S4802_005_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	005	0		29	10	S4802_005_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	005	0		29	10	S4802_005_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	005	0		29	10	S4802_005_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	006	0		29	10	S4802_006_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	006	0		29	10	S4802_006_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	006	0		29	10	S4802_006_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	006	0		29	10	S4802_006_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	007	0		29	10	S4802_007_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	007	0		29	10	S4802_007_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	007	0		29	10	S4802_007_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	007	0		29	10	S4802_007_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	008	0		29	10	S4802_008_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	008	0		29	10	S4802_008_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	008	0		29	10	S4802_008_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	008	0		29	10	S4802_008_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	009	0		29	10	S4802_009_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	009	0		29	10	S4802_009_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	009	0		29	10	S4802_009_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	009	0		29	10	S4802_009_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	010	0		29	10	S4802_010_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	010	0		29	10	S4802_010_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	010	0		29	10	S4802_010_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	010	0		29	10	S4802_010_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	011	0		29	10	S4802_011_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	011	0		29	10	S4802_011_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	011	0		29	10	S4802_011_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	011	0		29	10	S4802_011_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	012	0		29	10	S4802_012_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	012	0		29	10	S4802_012_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	012	0		29	10	S4802_012_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	012	0		29	10	S4802_012_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	013	0		29	10	S4802_013_0	5	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	013	0		29	10	S4802_013_0	5	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	013	0		29	10	S4802_013_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	013	0		29	10	S4802_013_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00									55.00		110.00								55.00
S4802	014	0		29	10	S4802_014_0	5	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	014	0		29	10	S4802_014_0	5	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	014	0		29	10	S4802_014_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	014	0		29	10	S4802_014_0	5	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	015	0		29	10	S4802_015_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	015	0		29	10	S4802_015_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	015	0		29	10	S4802_015_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	015	0		29	10	S4802_015_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	016	0		29	10	S4802_016_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	016	0		29	10	S4802_016_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	016	0		29	10	S4802_016_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	016	0		29	10	S4802_016_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	017	0		29	10	S4802_017_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	017	0		29	10	S4802_017_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	017	0		29	10	S4802_017_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	017	0		29	10	S4802_017_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	018	0		29	10	S4802_018_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	018	0		29	10	S4802_018_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	018	0		29	10	S4802_018_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	018	0		29	10	S4802_018_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	019	0		29	10	S4802_019_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	019	0		29	10	S4802_019_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	019	0		29	10	S4802_019_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	019	0		29	10	S4802_019_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	020	0		29	10	S4802_020_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	020	0		29	10	S4802_020_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	020	0		29	10	S4802_020_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	020	0		29	10	S4802_020_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	021	0		29	10	S4802_021_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	021	0		29	10	S4802_021_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	021	0		29	10	S4802_021_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	021	0		29	10	S4802_021_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	022	0		29	10	S4802_022_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	022	0		29	10	S4802_022_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	022	0		29	10	S4802_022_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	022	0		29	10	S4802_022_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	023	0		29	10	S4802_023_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	023	0		29	10	S4802_023_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	023	0		29	10	S4802_023_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	023	0		29	10	S4802_023_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	024	0		29	10	S4802_024_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	024	0		29	10	S4802_024_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	024	0		29	10	S4802_024_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	024	0		29	10	S4802_024_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	025	0		29	10	S4802_025_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	025	0		29	10	S4802_025_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	025	0		29	10	S4802_025_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00									58.00		116.00								58.00
S4802	025	0		29	10	S4802_025_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	026	0		29	10	S4802_026_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	026	0		29	10	S4802_026_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	026	0		29	10	S4802_026_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	026	0		29	10	S4802_026_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	027	0		29	10	S4802_027_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	027	0		29	10	S4802_027_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	027	0		29	10	S4802_027_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	027	0		29	10	S4802_027_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	028	0		29	10	S4802_028_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	028	0		29	10	S4802_028_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	028	0		29	10	S4802_028_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	028	0		29	10	S4802_028_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	029	0		29	10	S4802_029_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	029	0		29	10	S4802_029_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	029	0		29	10	S4802_029_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	029	0		29	10	S4802_029_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	030	0		29	10	S4802_030_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	030	0		29	10	S4802_030_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	030	0		29	10	S4802_030_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	030	0		29	10	S4802_030_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	031	0		29	10	S4802_031_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	031	0		29	10	S4802_031_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	031	0		29	10	S4802_031_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	031	0		29	10	S4802_031_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	032	0		29	10	S4802_032_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	032	0		29	10	S4802_032_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	032	0		29	10	S4802_032_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	032	0		29	10	S4802_032_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	033	0		29	10	S4802_033_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	033	0		29	10	S4802_033_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	033	0		29	10	S4802_033_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	033	0		29	10	S4802_033_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4802	067	0		29	10	S4802_067_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000001010000000	30	90									10									90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00		50.00								25.00
S4802	067	0		29	10	S4802_067_0	6	4	3	1	Specialty	000010		1				Specialty	111000000001010000000	30	90									10									90	31	Specialty	2	1	Specialty	25	25									25		25								25	Specialty																					
S4802	067	0		29	10	S4802_067_0	6	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000001010000000	30	90									10									90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00									57.00		114.00								57.00
S4802	067	0		29	10	S4802_067_0	6	1	3	1	Generic	010000		2				Generic	111000000001010000000	30	90									10									90	31	Generic	2	2	Generic																						Generic	7.00	21.00									7.00		14.00								7.00
S4877	002	0		29	10	S4877_002_0	3	4	4	1	Brand  Specialty	000010	1	1				Brand  Specialty	111000000010000000000	30	90								30											31	Brand  Specialty	2	2	Brand  Specialty																						Brand  Specialty	40.00	70.00								40.00											40.00
S4877	002	0		29	10	S4877_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	50.00								30.00											30.00
S4877	002	0		29	10	S4877_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	50.00								30.00											30.00
S4877	002	0		29	10	S4877_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S4877	002	0		29	10	S4877_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S4877	002	0		29	10	S4877_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S4877	002	0		29	10	S4877_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S4877	002	0		29	10	S4877_002_0	3	4	4	3	Brand  Specialty	000010	1	1	2			Brand  Specialty																							Brand  Specialty			Brand  Specialty																						Brand  Specialty																					
S5540	002	0		29	10	S5540_002_0	2	1	3	1	Tier 1 - Generic	010000		2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
S5540	002	0		29	10	S5540_002_0	2	4	3	1	Tier 4 - Specialty	010010		1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
S5540	002	0		29	10	S5540_002_0	2	3	3	1	Tier 3 - Non-preferred Brand	100000		2				Tier 3 - Non-preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-preferred Brand	2	2	Tier 3 - Non-preferred Brand																						Tier 3 - Non-preferred Brand	75.00	225.00	150.00							75.00		75.00	225.00	150.00							75.00
S5540	002	0		29	10	S5540_002_0	2	2	3	1	Tier 2 - Preferred Brand	000001		2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00
S5540	004	0		29	10	S5540_004_0	2	4	4	3	Tier 4 - Specialty	010010	1	1	2			Tier 4 - Specialty																							Tier 4 - Specialty			Tier 4 - Specialty																						Tier 4 - Specialty																					
S5540	004	0		29	10	S5540_004_0	2	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2				Tier 3 - Non-Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 3 - Non-Preferred Brand	2	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	180.00	120.00							60.00
S5540	004	0		29	10	S5540_004_0	2	2	4	1	Tier 2 - Preferred Brand	000001	1	2				Tier 2 - Preferred Brand	111100000010111000000	30	90	60							30		30	60							90	31	Tier 2 - Preferred Brand	2	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00
S5540	004	0		29	10	S5540_004_0	2	1	4	1	Tier 1 - Generic	010000	1	2				Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
S5540	004	0		29	10	S5540_004_0	2	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	2			Tier 3 - Non-Preferred Brand																							Tier 3 - Non-Preferred Brand			Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																					
S5540	004	0		29	10	S5540_004_0	2	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2			Tier 2 - Preferred Brand																							Tier 2 - Preferred Brand			Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand																					
S5540	004	0		29	10	S5540_004_0	2	1	4	3	Tier 1 - Generic	010000	1	2	1		1	Tier 1 - Generic	111100000010111000000	30	90	60							30		30	60							90	31	Tier 1 - Generic	2	2	Tier 1 - Generic																						Tier 1 - Generic	8.00	24.00	16.00							8.00		8.00	24.00	16.00							8.00
S5540	004	0		29	10	S5540_004_0	2	4	4	1	Tier 4 - Specialty	010010	1	1				Tier 4 - Specialty	111100000010111000000	30	90	60							30		30	60							90	31	Tier 4 - Specialty	2	1	Tier 4 - Specialty	33	33	33							33		33	33	33							33	Tier 4 - Specialty																					
S5552	001	0		29	10	S5552_001_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5552	001	0		29	10	S5552_001_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5552	001	0		29	10	S5552_001_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5552	001	0		29	10	S5552_001_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5552	002	0		29	10	S5552_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5552	002	0		29	10	S5552_002_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5552	002	0		29	10	S5552_002_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5552	002	0		29	10	S5552_002_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5552	002	0		29	10	S5552_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5552	002	0		29	10	S5552_002_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5552	002	0		29	10	S5552_002_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5552	002	0		29	10	S5552_002_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5552	003	0		29	10	S5552_003_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	10	10								10		10	10								10	Preferred Generic																					
S5552	003	0		29	10	S5552_003_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5552	003	0		29	10	S5552_003_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	42	42								42		42	42								42	Other - Non-Preferred (Gen/Brand)																					
S5555	001	0		29	10	S5555_001_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00
S5555	001	0		29	10	S5555_001_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00
S5555	001	0		29	10	S5555_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00
S5555	001	0		29	10	S5555_001_0	4	4	4	1	Specialty	110001	1	1				Specialty	111000000010110000000	30	90								30		30								90	31	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S5557	004	0		29	10	S5557_004_0	2	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				32.00	96.00		37.00	111.00		37.00		32.00	96.00								37.00
S5557	004	0		29	10	S5557_004_0	2	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
S5557	004	0		29	10	S5557_004_0	2	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				36.00	108.00		41.00	123.00		41.00		36.00	108.00								41.00
S5557	004	0		29	10	S5557_004_0	2	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	004	0		29	10	S5557_004_0	2	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	009	0		29	10	S5557_009_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	009	0		29	10	S5557_009_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	009	0		29	10	S5557_009_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	009	0		29	10	S5557_009_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	009	0		29	10	S5557_009_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	009	0		29	10	S5557_009_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	009	0		29	10	S5557_009_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	009	0		29	10	S5557_009_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	009	0		29	10	S5557_009_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	009	0		29	10	S5557_009_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	011	0		29	10	S5557_011_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	011	0		29	10	S5557_011_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	011	0		29	10	S5557_011_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	011	0		29	10	S5557_011_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	011	0		29	10	S5557_011_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	011	0		29	10	S5557_011_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	011	0		29	10	S5557_011_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	011	0		29	10	S5557_011_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	011	0		29	10	S5557_011_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	011	0		29	10	S5557_011_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	013	0		29	10	S5557_013_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	013	0		29	10	S5557_013_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	013	0		29	10	S5557_013_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	013	0		29	10	S5557_013_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	013	0		29	10	S5557_013_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	013	0		29	10	S5557_013_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	013	0		29	10	S5557_013_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	013	0		29	10	S5557_013_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	013	0		29	10	S5557_013_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	013	0		29	10	S5557_013_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	015	0		29	10	S5557_015_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	015	0		29	10	S5557_015_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	015	0		29	10	S5557_015_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	015	0		29	10	S5557_015_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	015	0		29	10	S5557_015_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	015	0		29	10	S5557_015_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	015	0		29	10	S5557_015_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	015	0		29	10	S5557_015_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	015	0		29	10	S5557_015_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	015	0		29	10	S5557_015_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	017	0		29	10	S5557_017_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	017	0		29	10	S5557_017_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	017	0		29	10	S5557_017_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	017	0		29	10	S5557_017_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	017	0		29	10	S5557_017_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	017	0		29	10	S5557_017_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	017	0		29	10	S5557_017_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	017	0		29	10	S5557_017_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	017	0		29	10	S5557_017_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	017	0		29	10	S5557_017_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	019	0		29	10	S5557_019_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	019	0		29	10	S5557_019_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	019	0		29	10	S5557_019_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	019	0		29	10	S5557_019_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	019	0		29	10	S5557_019_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	019	0		29	10	S5557_019_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	019	0		29	10	S5557_019_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	019	0		29	10	S5557_019_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	019	0		29	10	S5557_019_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	019	0		29	10	S5557_019_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	021	0		29	10	S5557_021_0	5	4	4	1	Tier 4	100000	1	2				Tier 4	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00					75.00	150.00		80.00	160.00		80.00
S5557	021	0		29	10	S5557_021_0	5	3	4	1	Tier 3	000001	1	2				Tier 3	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00					35.00	70.00		40.00	80.00		40.00
S5557	021	0		29	10	S5557_021_0	5	2	4	1	Tier 2	010000	1	2				Tier 2	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2				19.00	57.00		24.00	72.00		24.00					19.00	38.00		24.00	48.00		24.00
S5557	021	0		29	10	S5557_021_0	5	1	4	1	Tier 1	001000	1	2				Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	021	0		29	10	S5557_021_0	5	5	4	3	Tier 5	010010	1	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S5557	021	0		29	10	S5557_021_0	5	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011011010000110110				30	90		30	90		30				30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00					0.00	0.00		5.00	10.00		5.00
S5557	021	0		29	10	S5557_021_0	5	2	4	3	Tier 2	010000	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5557	021	0		29	10	S5557_021_0	5	3	4	3	Tier 3	000001	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5557	021	0		29	10	S5557_021_0	5	4	4	3	Tier 4	100000	1	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5557	021	0		29	10	S5557_021_0	5	5	4	1	Tier 5	010010	1	1				Tier 5	100010010010000100100				30			30			30				30			30				31	Tier 5	2	1	Tier 5				25			25			25					25			25			25	Tier 5																					
S5557	023	0		29	10	S5557_023_0	3	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	023	0		29	10	S5557_023_0	3	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				33.00	99.00		38.00	114.00		38.00		33.00	99.00								38.00
S5557	023	0		29	10	S5557_023_0	3	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				29.00	87.00		34.00	102.00		34.00		29.00	87.00								34.00
S5557	023	0		29	10	S5557_023_0	3	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		10.00	30.00		10.00		0.00	0.00								10.00
S5557	023	0		29	10	S5557_023_0	3	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	024	0		29	10	S5557_024_0	3	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				17.00	51.00		22.00	66.00		22.00		17.00	51.00								22.00
S5557	024	0		29	10	S5557_024_0	3	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
S5557	024	0		29	10	S5557_024_0	3	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				33.00	99.00		38.00	114.00		38.00		33.00	99.00								38.00
S5557	024	0		29	10	S5557_024_0	3	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	024	0		29	10	S5557_024_0	3	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	025	0		29	10	S5557_025_0	2	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				27.00	81.00		32.00	96.00		32.00		27.00	81.00								32.00
S5557	025	0		29	10	S5557_025_0	2	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		6.00	18.00		6.00		0.00	0.00								6.00
S5557	025	0		29	10	S5557_025_0	2	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				34.00	102.00		39.00	117.00		39.00		34.00	102.00								39.00
S5557	025	0		29	10	S5557_025_0	2	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	025	0		29	10	S5557_025_0	2	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	028	0		29	10	S5557_028_0	2	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00
S5557	028	0		29	10	S5557_028_0	2	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				27.00	81.00		32.00	96.00		32.00		27.00	81.00								32.00
S5557	028	0		29	10	S5557_028_0	2	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	028	0		29	10	S5557_028_0	2	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				34.00	102.00		39.00	117.00		39.00		34.00	102.00								39.00
S5557	028	0		29	10	S5557_028_0	2	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	031	0		29	10	S5557_031_0	3	1	3	1	Tier 1	001000		2				Tier 1	100011011010110000000				30	90		30	90		30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1				0.00	0.00		10.00	30.00		10.00		0.00	0.00								10.00
S5557	031	0		29	10	S5557_031_0	3	2	3	1	Tier 2	010000		2				Tier 2	100011011010110000000				30	90		30	90		30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2				30.00	90.00		35.00	105.00		35.00		30.00	90.00								35.00
S5557	031	0		29	10	S5557_031_0	3	5	3	1	Tier 5	010010		1				Tier 5	100010010010100000000				30			30			30		30									31	Tier 5	2	1	Tier 5				25			25			25		25									25	Tier 5																					
S5557	031	0		29	10	S5557_031_0	3	4	3	1	Tier 4	100000		2				Tier 4	100011011010110000000				30	90		30	90		30		30								90	31	Tier 4	2	2	Tier 4																						Tier 4				75.00	225.00		80.00	240.00		80.00		75.00	225.00								80.00
S5557	031	0		29	10	S5557_031_0	3	3	3	1	Tier 3	000001		2				Tier 3	100011011010110000000				30	90		30	90		30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3				35.00	105.00		40.00	120.00		40.00		35.00	105.00								40.00
S5566	001	0		29	10	S5566_001_0	1	4	2	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				25	25		25	25		25											25	Specialty																					
S5566	001	0		29	10	S5566_001_0	1	3	2	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				57.00	142.50		57.00	171.00		57.00			142.50								57.00
S5566	001	0		29	10	S5566_001_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				27.00	67.50		27.00	81.00		27.00			67.50								27.00
S5566	001	0		29	10	S5566_001_0	1	1	2	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				6.00	15.00		6.00	18.00		6.00			15.00								6.00
S5566	002	0		29	10	S5566_002_0	2	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5566	002	0		29	10	S5566_002_0	2	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				73.00	182.50		73.00	219.00		73.00			182.50								73.00
S5566	002	0		29	10	S5566_002_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				43.00	107.50		43.00	129.00		43.00			107.50								43.00
S5566	002	0		29	10	S5566_002_0	2	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				8.00	20.00		8.00	24.00		8.00			20.00								8.00
S5566	003	0		29	10	S5566_003_0	3	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5566	003	0		29	10	S5566_003_0	3	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5566	003	0		29	10	S5566_003_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5566	003	0		29	10	S5566_003_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				6.00	15.00		6.00	18.00		6.00			15.00								6.00
S5566	003	0		29	10	S5566_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5566	003	0		29	10	S5566_003_0	3	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
S5566	003	0		29	10	S5566_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				34.00	85.00		34.00	102.00		34.00			85.00								34.00
S5566	003	0		29	10	S5566_003_0	3	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				6.00	15.00		6.00	18.00		6.00			15.00								6.00
S5569	003	0		29	10	S5569_003_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5569	003	0		29	10	S5569_003_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5569	003	0		29	10	S5569_003_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5569	003	0		29	10	S5569_003_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5569	005	0		29	10	S5569_005_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5569	005	0		29	10	S5569_005_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5569	005	0		29	10	S5569_005_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	47.00	141.00								47.00											47.00
S5569	005	0		29	10	S5569_005_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5580	003	0		29	10	S5580_003_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	88.00								35.00			70.00								35.00
S5580	003	0		29	10	S5580_003_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00
S5580	003	0		29	10	S5580_003_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			140.00								70.00
S5580	003	0		29	10	S5580_003_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5580	004	0		29	10	S5580_004_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5580	004	0		29	10	S5580_004_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5580	004	0		29	10	S5580_004_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5580	004	0		29	10	S5580_004_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5584	001	0		29	10	S5584_001_0	5	1	3	1	Generic	001000		2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
S5584	001	0		29	10	S5584_001_0	5	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
S5584	001	0		29	10	S5584_001_0	5	3	3	1	Non Preferred	100100		2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
S5584	001	0		29	10	S5584_001_0	5	4	3	1	Specialty	010010		1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
S5584	001	0		29	10	S5584_001_0	5	5	3	1	Non Self Administered Injectable	010010		2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
S5584	002	0		29	10	S5584_002_0	4	1	4	1	Generic	001000	3	2				Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
S5584	002	0		29	10	S5584_002_0	4	5	4	3	Non Self Administered Injectable	010010	1	2	2			Non Self Administered Injectable																							Non Self Administered Injectable			Non Self Administered Injectable																						Non Self Administered Injectable																					
S5584	002	0		29	10	S5584_002_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5584	002	0		29	10	S5584_002_0	4	3	4	3	Non Preferred	100100	1	2	2			Non Preferred																							Non Preferred			Non Preferred																						Non Preferred																					
S5584	002	0		29	10	S5584_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00					30.00	75.00		30.00	90.00		30.00
S5584	002	0		29	10	S5584_002_0	4	3	4	1	Non Preferred	100100	1	2				Non Preferred	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Non Preferred	1	2	Non Preferred																						Non Preferred				55.00	137.50		55.00	165.00		55.00					55.00	137.50		55.00	165.00		55.00
S5584	002	0		29	10	S5584_002_0	4	4	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				25			25			25											25	Specialty																					
S5584	002	0		29	10	S5584_002_0	4	5	4	1	Non Self Administered Injectable	010010	1	2				Non Self Administered Injectable	100010010010000000000				34			34			34											34	Non Self Administered Injectable	1	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																					
S5584	002	0		29	10	S5584_002_0	4	1	4	3	Generic	001000	3	2	1		1	Generic	100011011010000110110				34	90		34	90		34				34	90		34	90			34	Generic	2	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00
S5584	002	0		29	10	S5584_002_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5585	001	0		29	10	S5585_001_0	2	3	3	1	Non-Preferred Brand/Generic	100100		2				Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand/Generic	2	1	Non-Preferred Brand/Generic	45	45								45		45	37								45	Non-Preferred Brand/Generic																					
S5585	001	0		29	10	S5585_001_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00
S5585	001	0		29	10	S5585_001_0	2	1	3	1	Formulary Generic	001000		2				Formulary Generic	111000000010110000000	30	90								30		30								90	31	Formulary Generic	2	2	Formulary Generic																						Formulary Generic	6.00	18.00								6.00		6.00	15.00								6.00
S5585	001	0		29	10	S5585_001_0	2	4	3	1	Specialty Injectables	100001		1				Specialty Injectables	111000000010110000000	30	90								30		30								90	31	Specialty Injectables	2	1	Specialty Injectables	33	33								33		33	27								33	Specialty Injectables																					
S5593	002	0		29	10	S5593_002_0	7	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
S5593	002	0		29	10	S5593_002_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00
S5593	002	0		29	10	S5593_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		162.50	162.50								65.00
S5593	002	0		29	10	S5593_002_0	7	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
S5593	003	0		29	10	S5593_003_0	5	4	4	3	Specialty	111111	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5593	003	0		29	10	S5593_003_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
S5593	003	0		29	10	S5593_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5593	003	0		29	10	S5593_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5593	003	0		29	10	S5593_003_0	5	4	4	1	Specialty	111111	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
S5593	003	0		29	10	S5593_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00		137.50	137.50								55.00
S5593	003	0		29	10	S5593_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		62.50	62.50								25.00
S5593	003	0		29	10	S5593_003_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00		12.50	12.50								5.00
S5593	004	0		29	10	S5593_004_0	5	1	2	1	Generic	010000		2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00
S5593	004	0		29	10	S5593_004_0	5	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00		80.00	80.00								32.00
S5593	004	0		29	10	S5593_004_0	5	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	186.00								62.00		155.00	155.00								62.00
S5593	004	0		29	10	S5593_004_0	5	4	2	1	Specialty	111111		1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S5596	001	0		29	10	S5596_001_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	001	0		29	10	S5596_001_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	001	0		29	10	S5596_001_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	001	0		29	10	S5596_001_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	001	0		29	10	S5596_001_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	003	0		29	10	S5596_003_0	4	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	003	0		29	10	S5596_003_0	4	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	003	0		29	10	S5596_003_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	003	0		29	10	S5596_003_0	4	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	003	0		29	10	S5596_003_0	4	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	003	0		29	10	S5596_003_0	4	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	003	0		29	10	S5596_003_0	4	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	003	0		29	10	S5596_003_0	4	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	003	0		29	10	S5596_003_0	4	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	003	0		29	10	S5596_003_0	4	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	005	0		29	10	S5596_005_0	3	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	005	0		29	10	S5596_005_0	3	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.50	133.50								44.50						111.25			133.50		44.50
S5596	005	0		29	10	S5596_005_0	3	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.50	25.50								8.50						12.75			25.50		8.50
S5596	005	0		29	10	S5596_005_0	3	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	005	0		29	10	S5596_005_0	3	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	006	0		29	10	S5596_006_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	006	0		29	10	S5596_006_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	006	0		29	10	S5596_006_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	006	0		29	10	S5596_006_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	006	0		29	10	S5596_006_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	007	0		29	10	S5596_007_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	007	0		29	10	S5596_007_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	007	0		29	10	S5596_007_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	007	0		29	10	S5596_007_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	007	0		29	10	S5596_007_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	007	0		29	10	S5596_007_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	007	0		29	10	S5596_007_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	007	0		29	10	S5596_007_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	007	0		29	10	S5596_007_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	007	0		29	10	S5596_007_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	009	0		29	10	S5596_009_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	009	0		29	10	S5596_009_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	009	0		29	10	S5596_009_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00
S5596	009	0		29	10	S5596_009_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	009	0		29	10	S5596_009_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	010	0		29	10	S5596_010_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	010	0		29	10	S5596_010_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	010	0		29	10	S5596_010_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	010	0		29	10	S5596_010_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	010	0		29	10	S5596_010_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	011	0		29	10	S5596_011_0	4	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	011	0		29	10	S5596_011_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	011	0		29	10	S5596_011_0	4	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	011	0		29	10	S5596_011_0	4	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	011	0		29	10	S5596_011_0	4	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	011	0		29	10	S5596_011_0	4	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	011	0		29	10	S5596_011_0	4	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	011	0		29	10	S5596_011_0	4	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	011	0		29	10	S5596_011_0	4	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	011	0		29	10	S5596_011_0	4	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	013	0		29	10	S5596_013_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.50	124.50								41.50						103.75			124.50		41.50
S5596	013	0		29	10	S5596_013_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	013	0		29	10	S5596_013_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	013	0		29	10	S5596_013_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	013	0		29	10	S5596_013_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	014	0		29	10	S5596_014_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	014	0		29	10	S5596_014_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	014	0		29	10	S5596_014_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	014	0		29	10	S5596_014_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	014	0		29	10	S5596_014_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	015	0		29	10	S5596_015_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	015	0		29	10	S5596_015_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	015	0		29	10	S5596_015_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	015	0		29	10	S5596_015_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	015	0		29	10	S5596_015_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	015	0		29	10	S5596_015_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	015	0		29	10	S5596_015_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	015	0		29	10	S5596_015_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	015	0		29	10	S5596_015_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	015	0		29	10	S5596_015_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	017	0		29	10	S5596_017_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	017	0		29	10	S5596_017_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00
S5596	017	0		29	10	S5596_017_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	017	0		29	10	S5596_017_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	017	0		29	10	S5596_017_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	018	0		29	10	S5596_018_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	018	0		29	10	S5596_018_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	018	0		29	10	S5596_018_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	018	0		29	10	S5596_018_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	018	0		29	10	S5596_018_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	019	0		29	10	S5596_019_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	019	0		29	10	S5596_019_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	019	0		29	10	S5596_019_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	019	0		29	10	S5596_019_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	019	0		29	10	S5596_019_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	019	0		29	10	S5596_019_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	019	0		29	10	S5596_019_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	019	0		29	10	S5596_019_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	019	0		29	10	S5596_019_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	019	0		29	10	S5596_019_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	021	0		29	10	S5596_021_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	021	0		29	10	S5596_021_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	021	0		29	10	S5596_021_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	021	0		29	10	S5596_021_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	021	0		29	10	S5596_021_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00								42.00						105.00			126.00		42.00
S5596	022	0		29	10	S5596_022_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	022	0		29	10	S5596_022_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	022	0		29	10	S5596_022_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	022	0		29	10	S5596_022_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	022	0		29	10	S5596_022_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	023	0		29	10	S5596_023_0	4	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	023	0		29	10	S5596_023_0	4	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	023	0		29	10	S5596_023_0	4	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	023	0		29	10	S5596_023_0	4	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	023	0		29	10	S5596_023_0	4	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	023	0		29	10	S5596_023_0	4	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	023	0		29	10	S5596_023_0	4	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	023	0		29	10	S5596_023_0	4	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	023	0		29	10	S5596_023_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	023	0		29	10	S5596_023_0	4	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	025	0		29	10	S5596_025_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	025	0		29	10	S5596_025_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	025	0		29	10	S5596_025_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	025	0		29	10	S5596_025_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	45.00	135.00								45.00						112.50			135.00		45.00
S5596	025	0		29	10	S5596_025_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	026	0		29	10	S5596_026_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	026	0		29	10	S5596_026_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	026	0		29	10	S5596_026_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	026	0		29	10	S5596_026_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	026	0		29	10	S5596_026_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	027	0		29	10	S5596_027_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	027	0		29	10	S5596_027_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	027	0		29	10	S5596_027_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	027	0		29	10	S5596_027_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	027	0		29	10	S5596_027_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	027	0		29	10	S5596_027_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	027	0		29	10	S5596_027_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	027	0		29	10	S5596_027_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	027	0		29	10	S5596_027_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	027	0		29	10	S5596_027_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	029	0		29	10	S5596_029_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	029	0		29	10	S5596_029_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	43.00	129.00								43.00						107.50			129.00		43.00
S5596	029	0		29	10	S5596_029_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	029	0		29	10	S5596_029_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	029	0		29	10	S5596_029_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	030	0		29	10	S5596_030_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	030	0		29	10	S5596_030_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	030	0		29	10	S5596_030_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	030	0		29	10	S5596_030_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	030	0		29	10	S5596_030_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	031	0		29	10	S5596_031_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	031	0		29	10	S5596_031_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	031	0		29	10	S5596_031_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	031	0		29	10	S5596_031_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	031	0		29	10	S5596_031_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	031	0		29	10	S5596_031_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	031	0		29	10	S5596_031_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	031	0		29	10	S5596_031_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	031	0		29	10	S5596_031_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	031	0		29	10	S5596_031_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	033	0		29	10	S5596_033_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	47.00	141.00								47.00						117.50			141.00		47.00
S5596	033	0		29	10	S5596_033_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	033	0		29	10	S5596_033_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	033	0		29	10	S5596_033_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	033	0		29	10	S5596_033_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	034	0		29	10	S5596_034_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	034	0		29	10	S5596_034_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	034	0		29	10	S5596_034_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	034	0		29	10	S5596_034_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	034	0		29	10	S5596_034_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	035	0		29	10	S5596_035_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	035	0		29	10	S5596_035_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	035	0		29	10	S5596_035_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	035	0		29	10	S5596_035_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	035	0		29	10	S5596_035_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	035	0		29	10	S5596_035_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	035	0		29	10	S5596_035_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	035	0		29	10	S5596_035_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	035	0		29	10	S5596_035_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	035	0		29	10	S5596_035_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	043	0		29	10	S5596_043_0	3	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00
S5596	043	0		29	10	S5596_043_0	3	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	043	0		29	10	S5596_043_0	3	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	043	0		29	10	S5596_043_0	3	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	043	0		29	10	S5596_043_0	3	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5596	044	0		29	10	S5596_044_0	4	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	044	0		29	10	S5596_044_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	044	0		29	10	S5596_044_0	4	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	044	0		29	10	S5596_044_0	4	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	044	0		29	10	S5596_044_0	4	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	045	0		29	10	S5596_045_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5596	045	0		29	10	S5596_045_0	4	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	045	0		29	10	S5596_045_0	4	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5596	045	0		29	10	S5596_045_0	4	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5596	045	0		29	10	S5596_045_0	4	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5596	045	0		29	10	S5596_045_0	4	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5596	045	0		29	10	S5596_045_0	4	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5596	045	0		29	10	S5596_045_0	4	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5596	045	0		29	10	S5596_045_0	4	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5596	045	0		29	10	S5596_045_0	4	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5596	046	0		29	10	S5596_046_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5596	046	0		29	10	S5596_046_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5596	046	0		29	10	S5596_046_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5596	046	0		29	10	S5596_046_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.00	132.00								44.00						110.00			132.00		44.00
S5596	046	0		29	10	S5596_046_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5597	034	0		29	10	S5597_034_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	034	0		29	10	S5597_034_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	034	0		29	10	S5597_034_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	035	0		29	10	S5597_035_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	035	0		29	10	S5597_035_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	035	0		29	10	S5597_035_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	036	0		29	10	S5597_036_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	036	0		29	10	S5597_036_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	036	0		29	10	S5597_036_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	037	0		29	10	S5597_037_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	037	0		29	10	S5597_037_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	037	0		29	10	S5597_037_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	038	0		29	10	S5597_038_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	038	0		29	10	S5597_038_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	038	0		29	10	S5597_038_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	039	0		29	10	S5597_039_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	039	0		29	10	S5597_039_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	039	0		29	10	S5597_039_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	040	0		29	10	S5597_040_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	040	0		29	10	S5597_040_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	040	0		29	10	S5597_040_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	041	0		29	10	S5597_041_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	041	0		29	10	S5597_041_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	041	0		29	10	S5597_041_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	042	0		29	10	S5597_042_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	042	0		29	10	S5597_042_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	042	0		29	10	S5597_042_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	043	0		29	10	S5597_043_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	043	0		29	10	S5597_043_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	043	0		29	10	S5597_043_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	044	0		29	10	S5597_044_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	044	0		29	10	S5597_044_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	044	0		29	10	S5597_044_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	045	0		29	10	S5597_045_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	045	0		29	10	S5597_045_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	045	0		29	10	S5597_045_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	046	0		29	10	S5597_046_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	046	0		29	10	S5597_046_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	046	0		29	10	S5597_046_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	047	0		29	10	S5597_047_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	047	0		29	10	S5597_047_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	047	0		29	10	S5597_047_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	048	0		29	10	S5597_048_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	048	0		29	10	S5597_048_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	048	0		29	10	S5597_048_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	049	0		29	10	S5597_049_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	049	0		29	10	S5597_049_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	049	0		29	10	S5597_049_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	050	0		29	10	S5597_050_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	050	0		29	10	S5597_050_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	050	0		29	10	S5597_050_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	051	0		29	10	S5597_051_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	051	0		29	10	S5597_051_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	051	0		29	10	S5597_051_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	052	0		29	10	S5597_052_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	052	0		29	10	S5597_052_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	052	0		29	10	S5597_052_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	053	0		29	10	S5597_053_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	053	0		29	10	S5597_053_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	053	0		29	10	S5597_053_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	054	0		29	10	S5597_054_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	054	0		29	10	S5597_054_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	054	0		29	10	S5597_054_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	055	0		29	10	S5597_055_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	055	0		29	10	S5597_055_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	055	0		29	10	S5597_055_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	056	0		29	10	S5597_056_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	056	0		29	10	S5597_056_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	056	0		29	10	S5597_056_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	057	0		29	10	S5597_057_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	057	0		29	10	S5597_057_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	057	0		29	10	S5597_057_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	058	0		29	10	S5597_058_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	058	0		29	10	S5597_058_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	058	0		29	10	S5597_058_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	059	0		29	10	S5597_059_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	059	0		29	10	S5597_059_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	059	0		29	10	S5597_059_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	060	0		29	10	S5597_060_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	060	0		29	10	S5597_060_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	060	0		29	10	S5597_060_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	061	0		29	10	S5597_061_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	061	0		29	10	S5597_061_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	061	0		29	10	S5597_061_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	062	0		29	10	S5597_062_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	062	0		29	10	S5597_062_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	062	0		29	10	S5597_062_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	063	0		29	10	S5597_063_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	063	0		29	10	S5597_063_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	063	0		29	10	S5597_063_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	064	0		29	10	S5597_064_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	064	0		29	10	S5597_064_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	064	0		29	10	S5597_064_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	199	0		29	10	S5597_199_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	199	0		29	10	S5597_199_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	199	0		29	10	S5597_199_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	199	0		29	10	S5597_199_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	199	0		29	10	S5597_199_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	199	0		29	10	S5597_199_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	200	0		29	10	S5597_200_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	200	0		29	10	S5597_200_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	200	0		29	10	S5597_200_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	200	0		29	10	S5597_200_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	200	0		29	10	S5597_200_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	200	0		29	10	S5597_200_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	201	0		29	10	S5597_201_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	201	0		29	10	S5597_201_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	201	0		29	10	S5597_201_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	201	0		29	10	S5597_201_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	201	0		29	10	S5597_201_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	201	0		29	10	S5597_201_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	202	0		29	10	S5597_202_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	202	0		29	10	S5597_202_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	202	0		29	10	S5597_202_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	202	0		29	10	S5597_202_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	202	0		29	10	S5597_202_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	202	0		29	10	S5597_202_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	203	0		29	10	S5597_203_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	203	0		29	10	S5597_203_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	203	0		29	10	S5597_203_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	203	0		29	10	S5597_203_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	203	0		29	10	S5597_203_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	203	0		29	10	S5597_203_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	204	0		29	10	S5597_204_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	204	0		29	10	S5597_204_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	204	0		29	10	S5597_204_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	204	0		29	10	S5597_204_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	204	0		29	10	S5597_204_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	204	0		29	10	S5597_204_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	205	0		29	10	S5597_205_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	205	0		29	10	S5597_205_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	205	0		29	10	S5597_205_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	205	0		29	10	S5597_205_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	205	0		29	10	S5597_205_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	205	0		29	10	S5597_205_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	206	0		29	10	S5597_206_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	206	0		29	10	S5597_206_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	206	0		29	10	S5597_206_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	206	0		29	10	S5597_206_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	206	0		29	10	S5597_206_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	206	0		29	10	S5597_206_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	207	0		29	10	S5597_207_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	207	0		29	10	S5597_207_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	207	0		29	10	S5597_207_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	207	0		29	10	S5597_207_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	207	0		29	10	S5597_207_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	207	0		29	10	S5597_207_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	208	0		29	10	S5597_208_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	208	0		29	10	S5597_208_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	208	0		29	10	S5597_208_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	208	0		29	10	S5597_208_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	208	0		29	10	S5597_208_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	208	0		29	10	S5597_208_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	209	0		29	10	S5597_209_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	209	0		29	10	S5597_209_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	209	0		29	10	S5597_209_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	209	0		29	10	S5597_209_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	209	0		29	10	S5597_209_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	209	0		29	10	S5597_209_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	210	0		29	10	S5597_210_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	210	0		29	10	S5597_210_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	210	0		29	10	S5597_210_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	210	0		29	10	S5597_210_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	210	0		29	10	S5597_210_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	210	0		29	10	S5597_210_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	211	0		29	10	S5597_211_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	211	0		29	10	S5597_211_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	211	0		29	10	S5597_211_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	211	0		29	10	S5597_211_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	211	0		29	10	S5597_211_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	211	0		29	10	S5597_211_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	212	0		29	10	S5597_212_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	212	0		29	10	S5597_212_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	212	0		29	10	S5597_212_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	212	0		29	10	S5597_212_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	212	0		29	10	S5597_212_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	212	0		29	10	S5597_212_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	213	0		29	10	S5597_213_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	213	0		29	10	S5597_213_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	213	0		29	10	S5597_213_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	213	0		29	10	S5597_213_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	213	0		29	10	S5597_213_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	213	0		29	10	S5597_213_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	214	0		29	10	S5597_214_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	214	0		29	10	S5597_214_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	214	0		29	10	S5597_214_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	214	0		29	10	S5597_214_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	214	0		29	10	S5597_214_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	214	0		29	10	S5597_214_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	215	0		29	10	S5597_215_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	215	0		29	10	S5597_215_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	215	0		29	10	S5597_215_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	215	0		29	10	S5597_215_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	215	0		29	10	S5597_215_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	215	0		29	10	S5597_215_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	216	0		29	10	S5597_216_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	216	0		29	10	S5597_216_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	216	0		29	10	S5597_216_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	216	0		29	10	S5597_216_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	216	0		29	10	S5597_216_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	216	0		29	10	S5597_216_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	217	0		29	10	S5597_217_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	217	0		29	10	S5597_217_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	217	0		29	10	S5597_217_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	217	0		29	10	S5597_217_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	217	0		29	10	S5597_217_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	217	0		29	10	S5597_217_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	218	0		29	10	S5597_218_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	218	0		29	10	S5597_218_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	218	0		29	10	S5597_218_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	218	0		29	10	S5597_218_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	218	0		29	10	S5597_218_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	218	0		29	10	S5597_218_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	219	0		29	10	S5597_219_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	219	0		29	10	S5597_219_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	219	0		29	10	S5597_219_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	219	0		29	10	S5597_219_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	219	0		29	10	S5597_219_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	219	0		29	10	S5597_219_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	220	0		29	10	S5597_220_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	220	0		29	10	S5597_220_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	220	0		29	10	S5597_220_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	220	0		29	10	S5597_220_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	220	0		29	10	S5597_220_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	220	0		29	10	S5597_220_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	221	0		29	10	S5597_221_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	221	0		29	10	S5597_221_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	221	0		29	10	S5597_221_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	221	0		29	10	S5597_221_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	221	0		29	10	S5597_221_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	221	0		29	10	S5597_221_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	222	0		29	10	S5597_222_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	222	0		29	10	S5597_222_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	222	0		29	10	S5597_222_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	222	0		29	10	S5597_222_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	222	0		29	10	S5597_222_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	222	0		29	10	S5597_222_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	223	0		29	10	S5597_223_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	223	0		29	10	S5597_223_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	223	0		29	10	S5597_223_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	223	0		29	10	S5597_223_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	223	0		29	10	S5597_223_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	223	0		29	10	S5597_223_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	224	0		29	10	S5597_224_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	224	0		29	10	S5597_224_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	224	0		29	10	S5597_224_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	224	0		29	10	S5597_224_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	224	0		29	10	S5597_224_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	224	0		29	10	S5597_224_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	225	0		29	10	S5597_225_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	225	0		29	10	S5597_225_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	225	0		29	10	S5597_225_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	225	0		29	10	S5597_225_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	225	0		29	10	S5597_225_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	225	0		29	10	S5597_225_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	226	0		29	10	S5597_226_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	226	0		29	10	S5597_226_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	226	0		29	10	S5597_226_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	226	0		29	10	S5597_226_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	226	0		29	10	S5597_226_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	226	0		29	10	S5597_226_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	227	0		29	10	S5597_227_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	227	0		29	10	S5597_227_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	227	0		29	10	S5597_227_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	227	0		29	10	S5597_227_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	227	0		29	10	S5597_227_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	227	0		29	10	S5597_227_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	228	0		29	10	S5597_228_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	228	0		29	10	S5597_228_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	228	0		29	10	S5597_228_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	228	0		29	10	S5597_228_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	228	0		29	10	S5597_228_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	228	0		29	10	S5597_228_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	229	0		29	10	S5597_229_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	229	0		29	10	S5597_229_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	229	0		29	10	S5597_229_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	229	0		29	10	S5597_229_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	229	0		29	10	S5597_229_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	229	0		29	10	S5597_229_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	230	0		29	10	S5597_230_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	230	0		29	10	S5597_230_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	230	0		29	10	S5597_230_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	232	0		29	10	S5597_232_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	232	0		29	10	S5597_232_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	232	0		29	10	S5597_232_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	232	0		29	10	S5597_232_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	232	0		29	10	S5597_232_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	232	0		29	10	S5597_232_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	233	0		29	10	S5597_233_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5597	233	0		29	10	S5597_233_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	233	0		29	10	S5597_233_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	235	0		29	10	S5597_235_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	235	0		29	10	S5597_235_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5597	235	0		29	10	S5597_235_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5597	235	0		29	10	S5597_235_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5597	235	0		29	10	S5597_235_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5597	235	0		29	10	S5597_235_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5601	002	0		29	10	S5601_002_0	9	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	002	0		29	10	S5601_002_0	9	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	002	0		29	10	S5601_002_0	9	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.50	109.50	73.00							36.50					27.50	82.25	55.00	36.50	109.50	73.00	36.50
S5601	002	0		29	10	S5601_002_0	9	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	003	0		29	10	S5601_003_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	003	0		29	10	S5601_003_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	003	0		29	10	S5601_003_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	003	0		29	10	S5601_003_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	003	0		29	10	S5601_003_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	003	0		29	10	S5601_003_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	003	0		29	10	S5601_003_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	003	0		29	10	S5601_003_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	003	0		29	10	S5601_003_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	003	0		29	10	S5601_003_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	003	0		29	10	S5601_003_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	003	0		29	10	S5601_003_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	004	0		29	10	S5601_004_0	8	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	004	0		29	10	S5601_004_0	8	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	004	0		29	10	S5601_004_0	8	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.25	117.75	78.50							39.25					29.50	88.25	59.00	39.25	117.75	78.50	39.25
S5601	004	0		29	10	S5601_004_0	8	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	005	0		29	10	S5601_005_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	005	0		29	10	S5601_005_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	005	0		29	10	S5601_005_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	005	0		29	10	S5601_005_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	005	0		29	10	S5601_005_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	005	0		29	10	S5601_005_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	005	0		29	10	S5601_005_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	005	0		29	10	S5601_005_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	005	0		29	10	S5601_005_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	005	0		29	10	S5601_005_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	005	0		29	10	S5601_005_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	005	0		29	10	S5601_005_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	006	0		29	10	S5601_006_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	006	0		29	10	S5601_006_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	006	0		29	10	S5601_006_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.75	101.25	67.50							33.75					25.25	76.00	50.50	33.75	101.25	67.50	33.75
S5601	006	0		29	10	S5601_006_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	007	0		29	10	S5601_007_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	007	0		29	10	S5601_007_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	007	0		29	10	S5601_007_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	007	0		29	10	S5601_007_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	007	0		29	10	S5601_007_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	007	0		29	10	S5601_007_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	007	0		29	10	S5601_007_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	007	0		29	10	S5601_007_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	007	0		29	10	S5601_007_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	007	0		29	10	S5601_007_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	007	0		29	10	S5601_007_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	007	0		29	10	S5601_007_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	008	0		29	10	S5601_008_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	008	0		29	10	S5601_008_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	008	0		29	10	S5601_008_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00					29.25	87.75	58.50	39.00	117.00	78.00	39.00
S5601	008	0		29	10	S5601_008_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	009	0		29	10	S5601_009_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	009	0		29	10	S5601_009_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	009	0		29	10	S5601_009_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	009	0		29	10	S5601_009_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	009	0		29	10	S5601_009_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	009	0		29	10	S5601_009_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	009	0		29	10	S5601_009_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	009	0		29	10	S5601_009_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	009	0		29	10	S5601_009_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	009	0		29	10	S5601_009_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	009	0		29	10	S5601_009_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	009	0		29	10	S5601_009_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	010	0		29	10	S5601_010_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	010	0		29	10	S5601_010_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00					31.50	94.50	63.00	42.00	126.00	84.00	42.00
S5601	010	0		29	10	S5601_010_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	010	0		29	10	S5601_010_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	011	0		29	10	S5601_011_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	011	0		29	10	S5601_011_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	011	0		29	10	S5601_011_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	011	0		29	10	S5601_011_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	011	0		29	10	S5601_011_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	011	0		29	10	S5601_011_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	011	0		29	10	S5601_011_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	011	0		29	10	S5601_011_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	011	0		29	10	S5601_011_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	011	0		29	10	S5601_011_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	011	0		29	10	S5601_011_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	011	0		29	10	S5601_011_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	012	0		29	10	S5601_012_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	012	0		29	10	S5601_012_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	012	0		29	10	S5601_012_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	012	0		29	10	S5601_012_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	93.00	62.00							31.00					23.25	69.75	46.50	31.00	93.00	62.00	31.00
S5601	013	0		29	10	S5601_013_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	013	0		29	10	S5601_013_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	013	0		29	10	S5601_013_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	013	0		29	10	S5601_013_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	013	0		29	10	S5601_013_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	013	0		29	10	S5601_013_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	013	0		29	10	S5601_013_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	013	0		29	10	S5601_013_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	013	0		29	10	S5601_013_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	013	0		29	10	S5601_013_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	013	0		29	10	S5601_013_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	013	0		29	10	S5601_013_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	014	0		29	10	S5601_014_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.75	104.25	69.50							34.75					26.00	78.25	52.00	34.75	104.25	69.50	34.75
S5601	014	0		29	10	S5601_014_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	014	0		29	10	S5601_014_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	014	0		29	10	S5601_014_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	015	0		29	10	S5601_015_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	015	0		29	10	S5601_015_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	015	0		29	10	S5601_015_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	015	0		29	10	S5601_015_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	015	0		29	10	S5601_015_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	015	0		29	10	S5601_015_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	015	0		29	10	S5601_015_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	015	0		29	10	S5601_015_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	015	0		29	10	S5601_015_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	015	0		29	10	S5601_015_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	015	0		29	10	S5601_015_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	015	0		29	10	S5601_015_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	016	0		29	10	S5601_016_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	016	0		29	10	S5601_016_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	016	0		29	10	S5601_016_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.75	101.25	67.50							33.75					25.25	76.00	50.50	33.75	101.25	67.50	33.75
S5601	016	0		29	10	S5601_016_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	017	0		29	10	S5601_017_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	017	0		29	10	S5601_017_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	017	0		29	10	S5601_017_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	017	0		29	10	S5601_017_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	017	0		29	10	S5601_017_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	017	0		29	10	S5601_017_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	017	0		29	10	S5601_017_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	017	0		29	10	S5601_017_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	017	0		29	10	S5601_017_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	017	0		29	10	S5601_017_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	017	0		29	10	S5601_017_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	017	0		29	10	S5601_017_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	018	0		29	10	S5601_018_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	018	0		29	10	S5601_018_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.75	98.25	65.50							32.75					24.50	73.75	49.00	32.75	98.25	65.50	32.75
S5601	018	0		29	10	S5601_018_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	018	0		29	10	S5601_018_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	019	0		29	10	S5601_019_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	019	0		29	10	S5601_019_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	019	0		29	10	S5601_019_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	019	0		29	10	S5601_019_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	019	0		29	10	S5601_019_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	019	0		29	10	S5601_019_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	019	0		29	10	S5601_019_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	019	0		29	10	S5601_019_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	019	0		29	10	S5601_019_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	019	0		29	10	S5601_019_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	019	0		29	10	S5601_019_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	019	0		29	10	S5601_019_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	020	0		29	10	S5601_020_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	020	0		29	10	S5601_020_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	020	0		29	10	S5601_020_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	020	0		29	10	S5601_020_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.25	105.75	70.50							35.25					26.50	79.25	53.00	35.25	105.75	70.50	35.25
S5601	021	0		29	10	S5601_021_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	021	0		29	10	S5601_021_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	021	0		29	10	S5601_021_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	021	0		29	10	S5601_021_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	021	0		29	10	S5601_021_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	021	0		29	10	S5601_021_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	021	0		29	10	S5601_021_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	021	0		29	10	S5601_021_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	021	0		29	10	S5601_021_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	021	0		29	10	S5601_021_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	021	0		29	10	S5601_021_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	021	0		29	10	S5601_021_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	022	0		29	10	S5601_022_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	022	0		29	10	S5601_022_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	022	0		29	10	S5601_022_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	022	0		29	10	S5601_022_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.50	115.50	77.00							38.50					29.00	86.75	58.00	38.50	115.50	77.00	38.50
S5601	023	0		29	10	S5601_023_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	023	0		29	10	S5601_023_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	023	0		29	10	S5601_023_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	023	0		29	10	S5601_023_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	023	0		29	10	S5601_023_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	023	0		29	10	S5601_023_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	023	0		29	10	S5601_023_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	023	0		29	10	S5601_023_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	023	0		29	10	S5601_023_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	023	0		29	10	S5601_023_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	023	0		29	10	S5601_023_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	023	0		29	10	S5601_023_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	024	0		29	10	S5601_024_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	024	0		29	10	S5601_024_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	024	0		29	10	S5601_024_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	024	0		29	10	S5601_024_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	41.50	124.50	83.00							41.50					31.25	93.50	62.50	41.50	124.50	83.00	41.50
S5601	025	0		29	10	S5601_025_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	025	0		29	10	S5601_025_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	025	0		29	10	S5601_025_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	025	0		29	10	S5601_025_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	025	0		29	10	S5601_025_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	025	0		29	10	S5601_025_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	025	0		29	10	S5601_025_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	025	0		29	10	S5601_025_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	025	0		29	10	S5601_025_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	025	0		29	10	S5601_025_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	025	0		29	10	S5601_025_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	025	0		29	10	S5601_025_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	026	0		29	10	S5601_026_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	026	0		29	10	S5601_026_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	026	0		29	10	S5601_026_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	026	0		29	10	S5601_026_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00					29.25	87.75	58.50	39.00	117.00	78.00	39.00
S5601	027	0		29	10	S5601_027_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	027	0		29	10	S5601_027_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	027	0		29	10	S5601_027_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	027	0		29	10	S5601_027_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	027	0		29	10	S5601_027_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	027	0		29	10	S5601_027_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	027	0		29	10	S5601_027_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	027	0		29	10	S5601_027_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	027	0		29	10	S5601_027_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	027	0		29	10	S5601_027_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	027	0		29	10	S5601_027_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	027	0		29	10	S5601_027_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	028	0		29	10	S5601_028_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	028	0		29	10	S5601_028_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	028	0		29	10	S5601_028_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	028	0		29	10	S5601_028_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.50	106.50	71.00							35.50					26.75	80.00	53.50	35.50	106.50	71.00	35.50
S5601	029	0		29	10	S5601_029_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	029	0		29	10	S5601_029_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	029	0		29	10	S5601_029_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	029	0		29	10	S5601_029_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	029	0		29	10	S5601_029_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	029	0		29	10	S5601_029_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	029	0		29	10	S5601_029_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	029	0		29	10	S5601_029_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	029	0		29	10	S5601_029_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	029	0		29	10	S5601_029_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	029	0		29	10	S5601_029_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	029	0		29	10	S5601_029_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	030	0		29	10	S5601_030_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	030	0		29	10	S5601_030_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.50	100.50	67.00							33.50					25.25	75.50	50.50	33.50	100.50	67.00	33.50
S5601	030	0		29	10	S5601_030_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	030	0		29	10	S5601_030_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	031	0		29	10	S5601_031_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	031	0		29	10	S5601_031_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	031	0		29	10	S5601_031_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	031	0		29	10	S5601_031_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	031	0		29	10	S5601_031_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	031	0		29	10	S5601_031_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	031	0		29	10	S5601_031_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	031	0		29	10	S5601_031_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	031	0		29	10	S5601_031_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	031	0		29	10	S5601_031_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	031	0		29	10	S5601_031_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	031	0		29	10	S5601_031_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	032	0		29	10	S5601_032_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	032	0		29	10	S5601_032_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	032	0		29	10	S5601_032_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.50	112.50	75.00							37.50					28.25	84.50	56.50	37.50	112.50	75.00	37.50
S5601	032	0		29	10	S5601_032_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	033	0		29	10	S5601_033_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	033	0		29	10	S5601_033_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	033	0		29	10	S5601_033_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	033	0		29	10	S5601_033_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	033	0		29	10	S5601_033_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	033	0		29	10	S5601_033_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	033	0		29	10	S5601_033_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	033	0		29	10	S5601_033_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	033	0		29	10	S5601_033_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	033	0		29	10	S5601_033_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	033	0		29	10	S5601_033_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	033	0		29	10	S5601_033_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	034	0		29	10	S5601_034_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	034	0		29	10	S5601_034_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.50	100.50	67.00							33.50					25.25	75.50	50.50	33.50	100.50	67.00	33.50
S5601	034	0		29	10	S5601_034_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	034	0		29	10	S5601_034_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	035	0		29	10	S5601_035_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	035	0		29	10	S5601_035_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	035	0		29	10	S5601_035_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	035	0		29	10	S5601_035_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	035	0		29	10	S5601_035_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	035	0		29	10	S5601_035_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	035	0		29	10	S5601_035_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	035	0		29	10	S5601_035_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	035	0		29	10	S5601_035_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	035	0		29	10	S5601_035_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	035	0		29	10	S5601_035_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	035	0		29	10	S5601_035_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	036	0		29	10	S5601_036_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	036	0		29	10	S5601_036_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	99.00	66.00							33.00					24.75	74.25	49.50	33.00	99.00	66.00	33.00
S5601	036	0		29	10	S5601_036_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	036	0		29	10	S5601_036_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	037	0		29	10	S5601_037_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	037	0		29	10	S5601_037_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	037	0		29	10	S5601_037_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	037	0		29	10	S5601_037_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	037	0		29	10	S5601_037_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	037	0		29	10	S5601_037_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	037	0		29	10	S5601_037_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	037	0		29	10	S5601_037_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	037	0		29	10	S5601_037_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	037	0		29	10	S5601_037_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	037	0		29	10	S5601_037_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	037	0		29	10	S5601_037_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	038	0		29	10	S5601_038_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	038	0		29	10	S5601_038_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.25	84.75	56.50							28.25					21.25	63.50	42.50	28.25	84.75	56.50	28.25
S5601	038	0		29	10	S5601_038_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	038	0		29	10	S5601_038_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	039	0		29	10	S5601_039_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	039	0		29	10	S5601_039_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	039	0		29	10	S5601_039_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	039	0		29	10	S5601_039_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	039	0		29	10	S5601_039_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	039	0		29	10	S5601_039_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	039	0		29	10	S5601_039_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	039	0		29	10	S5601_039_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	039	0		29	10	S5601_039_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	039	0		29	10	S5601_039_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	039	0		29	10	S5601_039_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	039	0		29	10	S5601_039_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	040	0		29	10	S5601_040_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	040	0		29	10	S5601_040_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.25	87.75	58.50							29.25					22.00	65.75	44.00	29.25	87.75	58.50	29.25
S5601	040	0		29	10	S5601_040_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	040	0		29	10	S5601_040_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	041	0		29	10	S5601_041_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	041	0		29	10	S5601_041_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	041	0		29	10	S5601_041_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	041	0		29	10	S5601_041_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	041	0		29	10	S5601_041_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	041	0		29	10	S5601_041_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	041	0		29	10	S5601_041_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	041	0		29	10	S5601_041_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	041	0		29	10	S5601_041_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	041	0		29	10	S5601_041_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	041	0		29	10	S5601_041_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	041	0		29	10	S5601_041_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	042	0		29	10	S5601_042_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	042	0		29	10	S5601_042_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.25	84.75	56.50							28.25					21.25	63.50	42.50	28.25	84.75	56.50	28.25
S5601	042	0		29	10	S5601_042_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	042	0		29	10	S5601_042_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	043	0		29	10	S5601_043_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	043	0		29	10	S5601_043_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	043	0		29	10	S5601_043_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	043	0		29	10	S5601_043_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	043	0		29	10	S5601_043_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	043	0		29	10	S5601_043_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	043	0		29	10	S5601_043_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	043	0		29	10	S5601_043_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	043	0		29	10	S5601_043_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	043	0		29	10	S5601_043_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	043	0		29	10	S5601_043_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	043	0		29	10	S5601_043_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	044	0		29	10	S5601_044_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	044	0		29	10	S5601_044_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	044	0		29	10	S5601_044_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	044	0		29	10	S5601_044_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00	76.00							38.00					28.50	85.50	57.00	38.00	114.00	76.00	38.00
S5601	045	0		29	10	S5601_045_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	045	0		29	10	S5601_045_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	045	0		29	10	S5601_045_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	045	0		29	10	S5601_045_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	045	0		29	10	S5601_045_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	045	0		29	10	S5601_045_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	045	0		29	10	S5601_045_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	045	0		29	10	S5601_045_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	045	0		29	10	S5601_045_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	045	0		29	10	S5601_045_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	045	0		29	10	S5601_045_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	045	0		29	10	S5601_045_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	046	0		29	10	S5601_046_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00					27.75	83.25	55.50	37.00	111.00	74.00	37.00
S5601	046	0		29	10	S5601_046_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	046	0		29	10	S5601_046_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	046	0		29	10	S5601_046_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	047	0		29	10	S5601_047_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	047	0		29	10	S5601_047_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	047	0		29	10	S5601_047_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	047	0		29	10	S5601_047_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	047	0		29	10	S5601_047_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	047	0		29	10	S5601_047_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	047	0		29	10	S5601_047_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	047	0		29	10	S5601_047_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	047	0		29	10	S5601_047_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	047	0		29	10	S5601_047_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	047	0		29	10	S5601_047_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	047	0		29	10	S5601_047_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	048	0		29	10	S5601_048_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	048	0		29	10	S5601_048_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.75	104.25	69.50							34.75					26.00	78.25	52.00	34.75	104.25	69.50	34.75
S5601	048	0		29	10	S5601_048_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	048	0		29	10	S5601_048_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	049	0		29	10	S5601_049_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	049	0		29	10	S5601_049_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	049	0		29	10	S5601_049_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	049	0		29	10	S5601_049_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	049	0		29	10	S5601_049_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	049	0		29	10	S5601_049_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	049	0		29	10	S5601_049_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	049	0		29	10	S5601_049_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	049	0		29	10	S5601_049_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	049	0		29	10	S5601_049_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	049	0		29	10	S5601_049_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	049	0		29	10	S5601_049_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	050	0		29	10	S5601_050_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	050	0		29	10	S5601_050_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	34.75	104.25	69.50							34.75					26.00	78.25	52.00	34.75	104.25	69.50	34.75
S5601	050	0		29	10	S5601_050_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	050	0		29	10	S5601_050_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	051	0		29	10	S5601_051_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	051	0		29	10	S5601_051_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	051	0		29	10	S5601_051_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	051	0		29	10	S5601_051_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	051	0		29	10	S5601_051_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	051	0		29	10	S5601_051_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	051	0		29	10	S5601_051_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	051	0		29	10	S5601_051_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	051	0		29	10	S5601_051_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	051	0		29	10	S5601_051_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	051	0		29	10	S5601_051_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	051	0		29	10	S5601_051_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	052	0		29	10	S5601_052_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	052	0		29	10	S5601_052_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	052	0		29	10	S5601_052_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	052	0		29	10	S5601_052_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.75	92.25	61.50							30.75					23.00	69.25	46.00	30.75	92.25	61.50	30.75
S5601	053	0		29	10	S5601_053_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	053	0		29	10	S5601_053_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	053	0		29	10	S5601_053_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	053	0		29	10	S5601_053_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	053	0		29	10	S5601_053_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	053	0		29	10	S5601_053_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	053	0		29	10	S5601_053_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	053	0		29	10	S5601_053_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	053	0		29	10	S5601_053_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	053	0		29	10	S5601_053_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	053	0		29	10	S5601_053_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	053	0		29	10	S5601_053_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	054	0		29	10	S5601_054_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.75	110.25	73.50							36.75					27.50	82.75	55.00	36.75	110.25	73.50	36.75
S5601	054	0		29	10	S5601_054_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	054	0		29	10	S5601_054_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	054	0		29	10	S5601_054_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	055	0		29	10	S5601_055_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	055	0		29	10	S5601_055_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	055	0		29	10	S5601_055_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	055	0		29	10	S5601_055_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	055	0		29	10	S5601_055_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	055	0		29	10	S5601_055_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	055	0		29	10	S5601_055_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	055	0		29	10	S5601_055_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	055	0		29	10	S5601_055_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	055	0		29	10	S5601_055_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	055	0		29	10	S5601_055_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	055	0		29	10	S5601_055_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	056	0		29	10	S5601_056_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	056	0		29	10	S5601_056_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	056	0		29	10	S5601_056_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.25	81.75	54.50							27.25					20.50	61.25	41.00	27.25	81.75	54.50	27.25
S5601	056	0		29	10	S5601_056_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	057	0		29	10	S5601_057_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	057	0		29	10	S5601_057_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	057	0		29	10	S5601_057_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	057	0		29	10	S5601_057_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	057	0		29	10	S5601_057_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	057	0		29	10	S5601_057_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	057	0		29	10	S5601_057_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	057	0		29	10	S5601_057_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	057	0		29	10	S5601_057_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	057	0		29	10	S5601_057_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	057	0		29	10	S5601_057_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	057	0		29	10	S5601_057_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	058	0		29	10	S5601_058_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	058	0		29	10	S5601_058_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.75	110.25	73.50							36.75					27.50	82.75	55.00	36.75	110.25	73.50	36.75
S5601	058	0		29	10	S5601_058_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	058	0		29	10	S5601_058_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	059	0		29	10	S5601_059_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	059	0		29	10	S5601_059_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	059	0		29	10	S5601_059_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	059	0		29	10	S5601_059_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	059	0		29	10	S5601_059_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	059	0		29	10	S5601_059_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	059	0		29	10	S5601_059_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	059	0		29	10	S5601_059_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	059	0		29	10	S5601_059_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	059	0		29	10	S5601_059_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	059	0		29	10	S5601_059_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	059	0		29	10	S5601_059_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	060	0		29	10	S5601_060_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	060	0		29	10	S5601_060_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	060	0		29	10	S5601_060_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	060	0		29	10	S5601_060_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.50	97.50	65.00							32.50					24.50	73.25	49.00	32.50	97.50	65.00	32.50
S5601	061	0		29	10	S5601_061_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	061	0		29	10	S5601_061_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	061	0		29	10	S5601_061_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	061	0		29	10	S5601_061_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	061	0		29	10	S5601_061_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	061	0		29	10	S5601_061_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	061	0		29	10	S5601_061_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	061	0		29	10	S5601_061_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	061	0		29	10	S5601_061_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	061	0		29	10	S5601_061_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	061	0		29	10	S5601_061_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	061	0		29	10	S5601_061_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	062	0		29	10	S5601_062_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	062	0		29	10	S5601_062_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	062	0		29	10	S5601_062_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	062	0		29	10	S5601_062_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	108.00	72.00							36.00					27.00	81.00	54.00	36.00	108.00	72.00	36.00
S5601	063	0		29	10	S5601_063_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	063	0		29	10	S5601_063_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	063	0		29	10	S5601_063_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	063	0		29	10	S5601_063_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	063	0		29	10	S5601_063_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	063	0		29	10	S5601_063_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	063	0		29	10	S5601_063_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	063	0		29	10	S5601_063_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	063	0		29	10	S5601_063_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	063	0		29	10	S5601_063_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	063	0		29	10	S5601_063_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	063	0		29	10	S5601_063_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	064	0		29	10	S5601_064_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	064	0		29	10	S5601_064_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	064	0		29	10	S5601_064_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	064	0		29	10	S5601_064_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.50	115.50	77.00							38.50					29.00	86.75	58.00	38.50	115.50	77.00	38.50
S5601	065	0		29	10	S5601_065_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	065	0		29	10	S5601_065_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	065	0		29	10	S5601_065_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	065	0		29	10	S5601_065_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	065	0		29	10	S5601_065_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	065	0		29	10	S5601_065_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	065	0		29	10	S5601_065_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	065	0		29	10	S5601_065_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	065	0		29	10	S5601_065_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	065	0		29	10	S5601_065_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	065	0		29	10	S5601_065_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	065	0		29	10	S5601_065_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	066	0		29	10	S5601_066_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	066	0		29	10	S5601_066_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	066	0		29	10	S5601_066_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	066	0		29	10	S5601_066_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00					26.25	78.75	52.50	35.00	105.00	70.00	35.00
S5601	067	0		29	10	S5601_067_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	067	0		29	10	S5601_067_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	067	0		29	10	S5601_067_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	067	0		29	10	S5601_067_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	067	0		29	10	S5601_067_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	067	0		29	10	S5601_067_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	067	0		29	10	S5601_067_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	067	0		29	10	S5601_067_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	067	0		29	10	S5601_067_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	067	0		29	10	S5601_067_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	067	0		29	10	S5601_067_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	067	0		29	10	S5601_067_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	068	0		29	10	S5601_068_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	068	0		29	10	S5601_068_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	068	0		29	10	S5601_068_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	98.00	294.00	196.00							98.00					89.75	269.50	179.50	98.00	294.00	196.00	98.00
S5601	068	0		29	10	S5601_068_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	21.00	63.00	42.00							21.00					15.75	47.25	31.50	21.00	63.00	42.00	21.00
S5601	069	0		29	10	S5601_069_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					3.25	10.00	6.50	9.00	27.00	18.00	9.00
S5601	069	0		29	10	S5601_069_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.75	23.00	15.50	9.00	27.00	18.00	9.00
S5601	069	0		29	10	S5601_069_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				30.00	90.00	60.00	35.00	105.00	70.00	35.00					23.75	71.00	47.50	35.00	105.00	70.00	35.00
S5601	069	0		29	10	S5601_069_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				35.00	105.00	70.00	35.00	105.00	70.00	35.00					27.25	82.00	54.50	35.00	105.00	70.00	35.00
S5601	069	0		29	10	S5601_069_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				95.00	285.00	190.00	95.00	285.00	190.00	95.00					87.00	261.00	174.00	95.00	285.00	190.00	95.00
S5601	069	0		29	10	S5601_069_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	069	0		29	10	S5601_069_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	069	0		29	10	S5601_069_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	069	0		29	10	S5601_069_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	069	0		29	10	S5601_069_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	069	0		29	10	S5601_069_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	069	0		29	10	S5601_069_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	070	0		29	10	S5601_070_0	7	4	2	1	Specialty	010010		1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	25									25											25	Specialty																					
S5601	070	0		29	10	S5601_070_0	7	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00					55.00	165.00	110.00	60.00	180.00	120.00	60.00
S5601	070	0		29	10	S5601_070_0	7	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.25	69.75	46.50							23.25					17.50	52.25	35.00	23.25	69.75	46.50	23.25
S5601	070	0		29	10	S5601_070_0	7	1	2	1	Generic	010000		2				Generic	111100000010000111111	34	90	60							34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic	8.00	24.00	16.00							8.00					4.00	12.00	8.00	8.00	24.00	16.00	8.00
S5601	071	0		29	10	S5601_071_0	4	5	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				85.00	255.00	170.00	85.00	255.00	170.00	85.00					78.00	233.75	156.00	85.00	255.00	170.00	85.00
S5601	071	0		29	10	S5601_071_0	4	6	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				31			31			31											31	Specialty																					
S5601	071	0		29	10	S5601_071_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	30.00	90.00	60.00	30.00					3.25	10.00	6.50	30.00	90.00	60.00	30.00
S5601	071	0		29	10	S5601_071_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	30.00	90.00	60.00	30.00					7.75	23.00	15.50	30.00	90.00	60.00	30.00
S5601	071	0		29	10	S5601_071_0	4	4	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				26.00	78.00	52.00	26.00	78.00	52.00	26.00					20.25	61.00	40.50	26.00	78.00	52.00	26.00
S5601	071	0		29	10	S5601_071_0	4	3	4	1	Value Brand	000001	1	2				Value Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Brand	2	2	Value Brand																						Value Brand				26.00	78.00	52.00	26.00	78.00	52.00	26.00					20.25	61.00	40.50	26.00	78.00	52.00	26.00
S5601	071	0		29	10	S5601_071_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				9.00	27.00	18.00	9.00	27.00	18.00	9.00					7.50	22.50	15.00	9.00	27.00	18.00	9.00
S5601	071	0		29	10	S5601_071_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				4.00	12.00	8.00	9.00	27.00	18.00	9.00					7.50	22.50	15.00	9.00	27.00	18.00	9.00
S5601	071	0		29	10	S5601_071_0	4	3	4	3	Value Brand	000001	1	2	2			Value Brand																							Value Brand			Value Brand																						Value Brand																					
S5601	071	0		29	10	S5601_071_0	4	6	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	071	0		29	10	S5601_071_0	4	5	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	071	0		29	10	S5601_071_0	4	4	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	072	0		29	10	S5601_072_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	072	0		29	10	S5601_072_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	072	0		29	10	S5601_072_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	072	0		29	10	S5601_072_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	072	0		29	10	S5601_072_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	072	0		29	10	S5601_072_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	072	0		29	10	S5601_072_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	072	0		29	10	S5601_072_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	072	0		29	10	S5601_072_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	072	0		29	10	S5601_072_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	073	0		29	10	S5601_073_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	073	0		29	10	S5601_073_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	073	0		29	10	S5601_073_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	073	0		29	10	S5601_073_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	073	0		29	10	S5601_073_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	073	0		29	10	S5601_073_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	073	0		29	10	S5601_073_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	073	0		29	10	S5601_073_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	073	0		29	10	S5601_073_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	073	0		29	10	S5601_073_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	074	0		29	10	S5601_074_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	074	0		29	10	S5601_074_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	074	0		29	10	S5601_074_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	074	0		29	10	S5601_074_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	074	0		29	10	S5601_074_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	074	0		29	10	S5601_074_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	074	0		29	10	S5601_074_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	074	0		29	10	S5601_074_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	074	0		29	10	S5601_074_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	074	0		29	10	S5601_074_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	075	0		29	10	S5601_075_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	075	0		29	10	S5601_075_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	075	0		29	10	S5601_075_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	075	0		29	10	S5601_075_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	075	0		29	10	S5601_075_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	075	0		29	10	S5601_075_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	075	0		29	10	S5601_075_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	075	0		29	10	S5601_075_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	075	0		29	10	S5601_075_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	075	0		29	10	S5601_075_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	076	0		29	10	S5601_076_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	076	0		29	10	S5601_076_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	076	0		29	10	S5601_076_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	076	0		29	10	S5601_076_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	076	0		29	10	S5601_076_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	076	0		29	10	S5601_076_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	076	0		29	10	S5601_076_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	076	0		29	10	S5601_076_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	076	0		29	10	S5601_076_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	076	0		29	10	S5601_076_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	077	0		29	10	S5601_077_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	077	0		29	10	S5601_077_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	077	0		29	10	S5601_077_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	077	0		29	10	S5601_077_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	077	0		29	10	S5601_077_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	077	0		29	10	S5601_077_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	077	0		29	10	S5601_077_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	077	0		29	10	S5601_077_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	077	0		29	10	S5601_077_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	077	0		29	10	S5601_077_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	078	0		29	10	S5601_078_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	078	0		29	10	S5601_078_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	078	0		29	10	S5601_078_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	078	0		29	10	S5601_078_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	078	0		29	10	S5601_078_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	078	0		29	10	S5601_078_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	078	0		29	10	S5601_078_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	078	0		29	10	S5601_078_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	078	0		29	10	S5601_078_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	078	0		29	10	S5601_078_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	079	0		29	10	S5601_079_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	079	0		29	10	S5601_079_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	079	0		29	10	S5601_079_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	079	0		29	10	S5601_079_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	079	0		29	10	S5601_079_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	079	0		29	10	S5601_079_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	079	0		29	10	S5601_079_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	079	0		29	10	S5601_079_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	079	0		29	10	S5601_079_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	079	0		29	10	S5601_079_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	080	0		29	10	S5601_080_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	080	0		29	10	S5601_080_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	080	0		29	10	S5601_080_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	080	0		29	10	S5601_080_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	080	0		29	10	S5601_080_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	080	0		29	10	S5601_080_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	080	0		29	10	S5601_080_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	080	0		29	10	S5601_080_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	080	0		29	10	S5601_080_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	080	0		29	10	S5601_080_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	081	0		29	10	S5601_081_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	081	0		29	10	S5601_081_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	081	0		29	10	S5601_081_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	081	0		29	10	S5601_081_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	081	0		29	10	S5601_081_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	081	0		29	10	S5601_081_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	081	0		29	10	S5601_081_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	081	0		29	10	S5601_081_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	081	0		29	10	S5601_081_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	081	0		29	10	S5601_081_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	082	0		29	10	S5601_082_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	082	0		29	10	S5601_082_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	082	0		29	10	S5601_082_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	082	0		29	10	S5601_082_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	082	0		29	10	S5601_082_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	082	0		29	10	S5601_082_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	082	0		29	10	S5601_082_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	082	0		29	10	S5601_082_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	082	0		29	10	S5601_082_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	082	0		29	10	S5601_082_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	083	0		29	10	S5601_083_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	083	0		29	10	S5601_083_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	083	0		29	10	S5601_083_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	083	0		29	10	S5601_083_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	083	0		29	10	S5601_083_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	083	0		29	10	S5601_083_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	083	0		29	10	S5601_083_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	083	0		29	10	S5601_083_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	083	0		29	10	S5601_083_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	083	0		29	10	S5601_083_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	084	0		29	10	S5601_084_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	084	0		29	10	S5601_084_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	084	0		29	10	S5601_084_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	084	0		29	10	S5601_084_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	084	0		29	10	S5601_084_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	084	0		29	10	S5601_084_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	084	0		29	10	S5601_084_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	084	0		29	10	S5601_084_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	084	0		29	10	S5601_084_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	084	0		29	10	S5601_084_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	085	0		29	10	S5601_085_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	085	0		29	10	S5601_085_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	085	0		29	10	S5601_085_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	085	0		29	10	S5601_085_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	085	0		29	10	S5601_085_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	085	0		29	10	S5601_085_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	085	0		29	10	S5601_085_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	085	0		29	10	S5601_085_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	085	0		29	10	S5601_085_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	085	0		29	10	S5601_085_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	086	0		29	10	S5601_086_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	086	0		29	10	S5601_086_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	086	0		29	10	S5601_086_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	086	0		29	10	S5601_086_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	086	0		29	10	S5601_086_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	086	0		29	10	S5601_086_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	086	0		29	10	S5601_086_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	086	0		29	10	S5601_086_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	086	0		29	10	S5601_086_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	086	0		29	10	S5601_086_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	087	0		29	10	S5601_087_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	087	0		29	10	S5601_087_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	087	0		29	10	S5601_087_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	087	0		29	10	S5601_087_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	087	0		29	10	S5601_087_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	087	0		29	10	S5601_087_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	087	0		29	10	S5601_087_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	087	0		29	10	S5601_087_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	087	0		29	10	S5601_087_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	087	0		29	10	S5601_087_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	088	0		29	10	S5601_088_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	088	0		29	10	S5601_088_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	088	0		29	10	S5601_088_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	088	0		29	10	S5601_088_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	088	0		29	10	S5601_088_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	088	0		29	10	S5601_088_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	088	0		29	10	S5601_088_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	088	0		29	10	S5601_088_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	088	0		29	10	S5601_088_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	088	0		29	10	S5601_088_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	089	0		29	10	S5601_089_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	089	0		29	10	S5601_089_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	089	0		29	10	S5601_089_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	089	0		29	10	S5601_089_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	089	0		29	10	S5601_089_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	089	0		29	10	S5601_089_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	089	0		29	10	S5601_089_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	089	0		29	10	S5601_089_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	089	0		29	10	S5601_089_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	089	0		29	10	S5601_089_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	090	0		29	10	S5601_090_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	090	0		29	10	S5601_090_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	090	0		29	10	S5601_090_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	090	0		29	10	S5601_090_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	090	0		29	10	S5601_090_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	090	0		29	10	S5601_090_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	090	0		29	10	S5601_090_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	090	0		29	10	S5601_090_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	090	0		29	10	S5601_090_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	090	0		29	10	S5601_090_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	091	0		29	10	S5601_091_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	091	0		29	10	S5601_091_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	091	0		29	10	S5601_091_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	091	0		29	10	S5601_091_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	091	0		29	10	S5601_091_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	091	0		29	10	S5601_091_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	091	0		29	10	S5601_091_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	091	0		29	10	S5601_091_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	091	0		29	10	S5601_091_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	091	0		29	10	S5601_091_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	092	0		29	10	S5601_092_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	092	0		29	10	S5601_092_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	092	0		29	10	S5601_092_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	092	0		29	10	S5601_092_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	092	0		29	10	S5601_092_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	092	0		29	10	S5601_092_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	092	0		29	10	S5601_092_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	092	0		29	10	S5601_092_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	092	0		29	10	S5601_092_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	092	0		29	10	S5601_092_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	093	0		29	10	S5601_093_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	093	0		29	10	S5601_093_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	093	0		29	10	S5601_093_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	093	0		29	10	S5601_093_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	093	0		29	10	S5601_093_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	093	0		29	10	S5601_093_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	093	0		29	10	S5601_093_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	093	0		29	10	S5601_093_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	093	0		29	10	S5601_093_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	093	0		29	10	S5601_093_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	094	0		29	10	S5601_094_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	094	0		29	10	S5601_094_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	094	0		29	10	S5601_094_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	094	0		29	10	S5601_094_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	094	0		29	10	S5601_094_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	094	0		29	10	S5601_094_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	094	0		29	10	S5601_094_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	094	0		29	10	S5601_094_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	094	0		29	10	S5601_094_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	094	0		29	10	S5601_094_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	095	0		29	10	S5601_095_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	095	0		29	10	S5601_095_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	095	0		29	10	S5601_095_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	095	0		29	10	S5601_095_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	095	0		29	10	S5601_095_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	095	0		29	10	S5601_095_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	095	0		29	10	S5601_095_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	095	0		29	10	S5601_095_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	095	0		29	10	S5601_095_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	095	0		29	10	S5601_095_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	096	0		29	10	S5601_096_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	096	0		29	10	S5601_096_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	096	0		29	10	S5601_096_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	096	0		29	10	S5601_096_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	096	0		29	10	S5601_096_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	096	0		29	10	S5601_096_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	096	0		29	10	S5601_096_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	096	0		29	10	S5601_096_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	096	0		29	10	S5601_096_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	096	0		29	10	S5601_096_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	097	0		29	10	S5601_097_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	097	0		29	10	S5601_097_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	097	0		29	10	S5601_097_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	097	0		29	10	S5601_097_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	097	0		29	10	S5601_097_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	097	0		29	10	S5601_097_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	097	0		29	10	S5601_097_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	097	0		29	10	S5601_097_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	097	0		29	10	S5601_097_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	097	0		29	10	S5601_097_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	098	0		29	10	S5601_098_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	098	0		29	10	S5601_098_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	098	0		29	10	S5601_098_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	098	0		29	10	S5601_098_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	098	0		29	10	S5601_098_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	098	0		29	10	S5601_098_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	098	0		29	10	S5601_098_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	098	0		29	10	S5601_098_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	098	0		29	10	S5601_098_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	098	0		29	10	S5601_098_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	099	0		29	10	S5601_099_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	099	0		29	10	S5601_099_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	099	0		29	10	S5601_099_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	099	0		29	10	S5601_099_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	099	0		29	10	S5601_099_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	099	0		29	10	S5601_099_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	099	0		29	10	S5601_099_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	099	0		29	10	S5601_099_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	099	0		29	10	S5601_099_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	099	0		29	10	S5601_099_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	100	0		29	10	S5601_100_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	100	0		29	10	S5601_100_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	100	0		29	10	S5601_100_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	100	0		29	10	S5601_100_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	100	0		29	10	S5601_100_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	100	0		29	10	S5601_100_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	100	0		29	10	S5601_100_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	100	0		29	10	S5601_100_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	100	0		29	10	S5601_100_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	100	0		29	10	S5601_100_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	101	0		29	10	S5601_101_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	101	0		29	10	S5601_101_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	101	0		29	10	S5601_101_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	101	0		29	10	S5601_101_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	101	0		29	10	S5601_101_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	101	0		29	10	S5601_101_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	101	0		29	10	S5601_101_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	101	0		29	10	S5601_101_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	101	0		29	10	S5601_101_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	101	0		29	10	S5601_101_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	102	0		29	10	S5601_102_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	102	0		29	10	S5601_102_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	102	0		29	10	S5601_102_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	102	0		29	10	S5601_102_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	102	0		29	10	S5601_102_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	102	0		29	10	S5601_102_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	102	0		29	10	S5601_102_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	102	0		29	10	S5601_102_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	102	0		29	10	S5601_102_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	102	0		29	10	S5601_102_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	103	0		29	10	S5601_103_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	103	0		29	10	S5601_103_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	103	0		29	10	S5601_103_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	103	0		29	10	S5601_103_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	103	0		29	10	S5601_103_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	103	0		29	10	S5601_103_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	103	0		29	10	S5601_103_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	103	0		29	10	S5601_103_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	103	0		29	10	S5601_103_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	103	0		29	10	S5601_103_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	104	0		29	10	S5601_104_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	104	0		29	10	S5601_104_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	104	0		29	10	S5601_104_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	104	0		29	10	S5601_104_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	104	0		29	10	S5601_104_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	104	0		29	10	S5601_104_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	104	0		29	10	S5601_104_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	104	0		29	10	S5601_104_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	104	0		29	10	S5601_104_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	104	0		29	10	S5601_104_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	105	0		29	10	S5601_105_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	105	0		29	10	S5601_105_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	105	0		29	10	S5601_105_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	105	0		29	10	S5601_105_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	105	0		29	10	S5601_105_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.25	19.00	12.50	7.50	22.50	15.00	7.50
S5601	105	0		29	10	S5601_105_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.50	7.50	5.00	7.50	22.50	15.00	7.50					2.00	6.00	4.00	7.50	22.50	15.00	7.50
S5601	105	0		29	10	S5601_105_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	105	0		29	10	S5601_105_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	105	0		29	10	S5601_105_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				98.00	294.00	196.00	98.00	294.00	196.00	98.00					90.00	270.00	180.00	98.00	294.00	196.00	98.00
S5601	105	0		29	10	S5601_105_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				39.00	117.00	78.00	39.00	117.00	78.00	39.00					30.75	92.00	61.50	39.00	117.00	78.00	39.00
S5601	106	0		29	10	S5601_106_0	4	1	4	3	Value Generic	001000	1	2	1		1	Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.00	6.00	4.00	7.50	22.50	15.00	7.50					5.75	17.50	11.50	7.50	22.50	15.00	7.50
S5601	106	0		29	10	S5601_106_0	4	5	4	1	Specialty	010010	1	1				Specialty	100010010010000000000				34			34			34											34	Specialty	2	1	Specialty				33			33			33											33	Specialty																					
S5601	106	0		29	10	S5601_106_0	4	4	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand				70.00	210.00	140.00	70.00	210.00	140.00	70.00					64.25	192.50	128.50	70.00	210.00	140.00	70.00
S5601	106	0		29	10	S5601_106_0	4	3	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				30.00	90.00	60.00	30.00	90.00	60.00	30.00					23.50	70.50	47.00	30.00	90.00	60.00	30.00
S5601	106	0		29	10	S5601_106_0	4	5	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5601	106	0		29	10	S5601_106_0	4	1	4	1	Value Generic	001000	1	2				Value Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Value Generic	2	2	Value Generic																						Value Generic				2.00	6.00	4.00	7.00	21.00	14.00	7.00					5.75	17.50	11.50	7.00	21.00	14.00	7.00
S5601	106	0		29	10	S5601_106_0	4	2	4	3	Generic	000100	1	2	1		1	Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.00	21.00	14.00	7.50	22.50	15.00	7.50					5.75	17.50	11.50	7.50	22.50	15.00	7.50
S5601	106	0		29	10	S5601_106_0	4	3	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5601	106	0		29	10	S5601_106_0	4	4	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5601	106	0		29	10	S5601_106_0	4	2	4	1	Generic	000100	1	2				Generic	100011111110000111111				34	90	60	34	90	60	34				34	90	60	34	90	60		34	Generic	2	2	Generic																						Generic				7.00	21.00	14.00	7.00	21.00	14.00	7.00					5.75	17.50	11.50	7.00	21.00	14.00	7.00
S5609	001	0		29	10	S5609_001_0	2	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
S5609	001	0		29	10	S5609_001_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
S5609	001	0		29	10	S5609_001_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
S5609	001	0		29	10	S5609_001_0	2	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5609	001	0		29	10	S5609_001_0	2	5	2	1	Specialty	110001		1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
S5609	002	0		29	10	S5609_002_0	2	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5609	002	0		29	10	S5609_002_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5609	002	0		29	10	S5609_002_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5609	002	0		29	10	S5609_002_0	2	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
S5609	002	0		29	10	S5609_002_0	2	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
S5609	002	0		29	10	S5609_002_0	2	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
S5609	002	0		29	10	S5609_002_0	2	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
S5609	002	0		29	10	S5609_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
S5609	002	0		29	10	S5609_002_0	2	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5609	002	0		29	10	S5609_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
S5617	003	0		29	10	S5617_003_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	003	0		29	10	S5617_003_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	003	0		29	10	S5617_003_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00									81.00				81.00	202.50		81.00	243.00		81.00
S5617	003	0		29	10	S5617_003_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	005	0		29	10	S5617_005_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	005	0		29	10	S5617_005_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	005	0		29	10	S5617_005_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	005	0		29	10	S5617_005_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	005	0		29	10	S5617_005_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	008	0		29	10	S5617_008_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00
S5617	008	0		29	10	S5617_008_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00
S5617	008	0		29	10	S5617_008_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	008	0		29	10	S5617_008_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	010	0		29	10	S5617_010_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	010	0		29	10	S5617_010_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	010	0		29	10	S5617_010_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	010	0		29	10	S5617_010_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	010	0		29	10	S5617_010_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	013	0		29	10	S5617_013_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	72.50	217.50									72.50				72.50	181.25		72.50	217.50		72.50
S5617	013	0		29	10	S5617_013_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00									25.00				25.00	62.50		25.00	75.00		25.00
S5617	013	0		29	10	S5617_013_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.00	6.00									2.00				2.00	5.00		2.00	6.00		2.00
S5617	013	0		29	10	S5617_013_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	015	0		29	10	S5617_015_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	015	0		29	10	S5617_015_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	015	0		29	10	S5617_015_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	015	0		29	10	S5617_015_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	015	0		29	10	S5617_015_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	018	0		29	10	S5617_018_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	018	0		29	10	S5617_018_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	018	0		29	10	S5617_018_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	77.00	231.00									77.00				77.00	192.50		77.00	231.00		77.00
S5617	018	0		29	10	S5617_018_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	020	0		29	10	S5617_020_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	020	0		29	10	S5617_020_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	020	0		29	10	S5617_020_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	36.00	108.00									36.00				36.00	90.00		36.00	108.00		36.00
S5617	020	0		29	10	S5617_020_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	020	0		29	10	S5617_020_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	023	0		29	10	S5617_023_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	023	0		29	10	S5617_023_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	023	0		29	10	S5617_023_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	023	0		29	10	S5617_023_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00
S5617	025	0		29	10	S5617_025_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	025	0		29	10	S5617_025_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	025	0		29	10	S5617_025_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	025	0		29	10	S5617_025_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	025	0		29	10	S5617_025_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	028	0		29	10	S5617_028_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	94.00	282.00									94.00				94.00	235.00		94.00	282.00		94.00
S5617	028	0		29	10	S5617_028_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	028	0		29	10	S5617_028_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	028	0		29	10	S5617_028_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	030	0		29	10	S5617_030_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00
S5617	030	0		29	10	S5617_030_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	030	0		29	10	S5617_030_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	030	0		29	10	S5617_030_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00
S5617	030	0		29	10	S5617_030_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	033	0		29	10	S5617_033_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00
S5617	033	0		29	10	S5617_033_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	033	0		29	10	S5617_033_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	033	0		29	10	S5617_033_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	035	0		29	10	S5617_035_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	035	0		29	10	S5617_035_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	035	0		29	10	S5617_035_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	035	0		29	10	S5617_035_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	035	0		29	10	S5617_035_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	038	0		29	10	S5617_038_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	038	0		29	10	S5617_038_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	038	0		29	10	S5617_038_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
S5617	038	0		29	10	S5617_038_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	040	0		29	10	S5617_040_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	39.00	117.00									39.00				39.00	97.50		39.00	117.00		39.00
S5617	040	0		29	10	S5617_040_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	040	0		29	10	S5617_040_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	040	0		29	10	S5617_040_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	040	0		29	10	S5617_040_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	043	0		29	10	S5617_043_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	76.00	228.00									76.00				76.00	190.00		76.00	228.00		76.00
S5617	043	0		29	10	S5617_043_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	043	0		29	10	S5617_043_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	043	0		29	10	S5617_043_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	045	0		29	10	S5617_045_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	045	0		29	10	S5617_045_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	045	0		29	10	S5617_045_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	045	0		29	10	S5617_045_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	045	0		29	10	S5617_045_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	048	0		29	10	S5617_048_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	048	0		29	10	S5617_048_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	048	0		29	10	S5617_048_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	73.00	219.00									73.00				73.00	182.50		73.00	219.00		73.00
S5617	048	0		29	10	S5617_048_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	050	0		29	10	S5617_050_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	050	0		29	10	S5617_050_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	050	0		29	10	S5617_050_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	050	0		29	10	S5617_050_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	050	0		29	10	S5617_050_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	053	0		29	10	S5617_053_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	053	0		29	10	S5617_053_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	053	0		29	10	S5617_053_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	71.00	213.00									71.00				71.00	177.50		71.00	213.00		71.00
S5617	053	0		29	10	S5617_053_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	055	0		29	10	S5617_055_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	055	0		29	10	S5617_055_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	055	0		29	10	S5617_055_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	055	0		29	10	S5617_055_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	36.00	108.00									36.00				36.00	90.00		36.00	108.00		36.00
S5617	055	0		29	10	S5617_055_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	058	0		29	10	S5617_058_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	058	0		29	10	S5617_058_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	058	0		29	10	S5617_058_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00									79.00				79.00	197.50		79.00	237.00		79.00
S5617	058	0		29	10	S5617_058_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	060	0		29	10	S5617_060_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	060	0		29	10	S5617_060_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	060	0		29	10	S5617_060_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	060	0		29	10	S5617_060_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	060	0		29	10	S5617_060_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	063	0		29	10	S5617_063_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00
S5617	063	0		29	10	S5617_063_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	063	0		29	10	S5617_063_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	063	0		29	10	S5617_063_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	065	0		29	10	S5617_065_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	065	0		29	10	S5617_065_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	065	0		29	10	S5617_065_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	43.00	129.00									43.00				43.00	107.50		43.00	129.00		43.00
S5617	065	0		29	10	S5617_065_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	065	0		29	10	S5617_065_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	068	0		29	10	S5617_068_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	068	0		29	10	S5617_068_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00
S5617	068	0		29	10	S5617_068_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	72.00	216.00									72.00				72.00	180.00		72.00	216.00		72.00
S5617	068	0		29	10	S5617_068_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	070	0		29	10	S5617_070_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	070	0		29	10	S5617_070_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	070	0		29	10	S5617_070_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	070	0		29	10	S5617_070_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	81.00	243.00									81.00				81.00	202.50		81.00	243.00		81.00
S5617	070	0		29	10	S5617_070_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	073	0		29	10	S5617_073_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00									79.00				79.00	197.50		79.00	237.00		79.00
S5617	073	0		29	10	S5617_073_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	073	0		29	10	S5617_073_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	073	0		29	10	S5617_073_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	075	0		29	10	S5617_075_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	075	0		29	10	S5617_075_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	075	0		29	10	S5617_075_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	075	0		29	10	S5617_075_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	075	0		29	10	S5617_075_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	078	0		29	10	S5617_078_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00
S5617	078	0		29	10	S5617_078_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	078	0		29	10	S5617_078_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00
S5617	078	0		29	10	S5617_078_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	080	0		29	10	S5617_080_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	080	0		29	10	S5617_080_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	080	0		29	10	S5617_080_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	080	0		29	10	S5617_080_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	080	0		29	10	S5617_080_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	083	0		29	10	S5617_083_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	083	0		29	10	S5617_083_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	083	0		29	10	S5617_083_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	083	0		29	10	S5617_083_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	085	0		29	10	S5617_085_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	085	0		29	10	S5617_085_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	085	0		29	10	S5617_085_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	085	0		29	10	S5617_085_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	085	0		29	10	S5617_085_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	088	0		29	10	S5617_088_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	088	0		29	10	S5617_088_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	088	0		29	10	S5617_088_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00
S5617	088	0		29	10	S5617_088_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	090	0		29	10	S5617_090_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	090	0		29	10	S5617_090_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	090	0		29	10	S5617_090_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	090	0		29	10	S5617_090_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	090	0		29	10	S5617_090_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	093	0		29	10	S5617_093_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	093	0		29	10	S5617_093_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	093	0		29	10	S5617_093_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	76.00	228.00									76.00				76.00	190.00		76.00	228.00		76.00
S5617	093	0		29	10	S5617_093_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	095	0		29	10	S5617_095_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	095	0		29	10	S5617_095_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	095	0		29	10	S5617_095_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	095	0		29	10	S5617_095_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	095	0		29	10	S5617_095_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	098	0		29	10	S5617_098_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	098	0		29	10	S5617_098_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	098	0		29	10	S5617_098_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	73.00	219.00									73.00				73.00	182.50		73.00	219.00		73.00
S5617	098	0		29	10	S5617_098_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	100	0		29	10	S5617_100_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	100	0		29	10	S5617_100_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	100	0		29	10	S5617_100_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	100	0		29	10	S5617_100_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	100	0		29	10	S5617_100_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	103	0		29	10	S5617_103_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	71.00	213.00									71.00				71.00	177.50		71.00	213.00		71.00
S5617	103	0		29	10	S5617_103_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	103	0		29	10	S5617_103_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	103	0		29	10	S5617_103_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	105	0		29	10	S5617_105_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	105	0		29	10	S5617_105_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	105	0		29	10	S5617_105_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	36.00	108.00									36.00				36.00	90.00		36.00	108.00		36.00
S5617	105	0		29	10	S5617_105_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	105	0		29	10	S5617_105_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	108	0		29	10	S5617_108_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	108	0		29	10	S5617_108_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	108	0		29	10	S5617_108_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
S5617	108	0		29	10	S5617_108_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	110	0		29	10	S5617_110_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	110	0		29	10	S5617_110_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	110	0		29	10	S5617_110_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	110	0		29	10	S5617_110_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	110	0		29	10	S5617_110_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	113	0		29	10	S5617_113_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	113	0		29	10	S5617_113_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	113	0		29	10	S5617_113_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	113	0		29	10	S5617_113_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	115	0		29	10	S5617_115_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	115	0		29	10	S5617_115_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	115	0		29	10	S5617_115_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	115	0		29	10	S5617_115_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	115	0		29	10	S5617_115_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	118	0		29	10	S5617_118_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00
S5617	118	0		29	10	S5617_118_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	118	0		29	10	S5617_118_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	118	0		29	10	S5617_118_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	120	0		29	10	S5617_120_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	120	0		29	10	S5617_120_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	120	0		29	10	S5617_120_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	120	0		29	10	S5617_120_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	120	0		29	10	S5617_120_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00
S5617	123	0		29	10	S5617_123_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00
S5617	123	0		29	10	S5617_123_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	123	0		29	10	S5617_123_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00
S5617	123	0		29	10	S5617_123_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	125	0		29	10	S5617_125_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	125	0		29	10	S5617_125_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	125	0		29	10	S5617_125_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	125	0		29	10	S5617_125_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	125	0		29	10	S5617_125_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	128	0		29	10	S5617_128_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	128	0		29	10	S5617_128_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	128	0		29	10	S5617_128_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	128	0		29	10	S5617_128_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	130	0		29	10	S5617_130_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	130	0		29	10	S5617_130_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	130	0		29	10	S5617_130_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	130	0		29	10	S5617_130_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	130	0		29	10	S5617_130_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	133	0		29	10	S5617_133_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00
S5617	133	0		29	10	S5617_133_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	133	0		29	10	S5617_133_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	133	0		29	10	S5617_133_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	135	0		29	10	S5617_135_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	135	0		29	10	S5617_135_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	135	0		29	10	S5617_135_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	44.00	132.00									44.00				44.00	110.00		44.00	132.00		44.00
S5617	135	0		29	10	S5617_135_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00
S5617	135	0		29	10	S5617_135_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	138	0		29	10	S5617_138_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00
S5617	138	0		29	10	S5617_138_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	138	0		29	10	S5617_138_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	95.00	285.00									95.00				95.00	237.50		95.00	285.00		95.00
S5617	138	0		29	10	S5617_138_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	140	0		29	10	S5617_140_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	140	0		29	10	S5617_140_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	140	0		29	10	S5617_140_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	140	0		29	10	S5617_140_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	140	0		29	10	S5617_140_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	143	0		29	10	S5617_143_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	143	0		29	10	S5617_143_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	28.00	84.00									28.00				28.00	70.00		28.00	84.00		28.00
S5617	143	0		29	10	S5617_143_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	143	0		29	10	S5617_143_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	145	0		29	10	S5617_145_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00
S5617	145	0		29	10	S5617_145_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	145	0		29	10	S5617_145_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	145	0		29	10	S5617_145_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	145	0		29	10	S5617_145_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	148	0		29	10	S5617_148_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	148	0		29	10	S5617_148_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	148	0		29	10	S5617_148_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00
S5617	148	0		29	10	S5617_148_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	150	0		29	10	S5617_150_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	150	0		29	10	S5617_150_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	150	0		29	10	S5617_150_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	150	0		29	10	S5617_150_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00
S5617	150	0		29	10	S5617_150_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	153	0		29	10	S5617_153_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	91.00	273.00									91.00				91.00	227.50		91.00	273.00		91.00
S5617	153	0		29	10	S5617_153_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	153	0		29	10	S5617_153_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00
S5617	153	0		29	10	S5617_153_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	155	0		29	10	S5617_155_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	155	0		29	10	S5617_155_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	155	0		29	10	S5617_155_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	155	0		29	10	S5617_155_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	155	0		29	10	S5617_155_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	158	0		29	10	S5617_158_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	158	0		29	10	S5617_158_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	158	0		29	10	S5617_158_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00									78.00				78.00	195.00		78.00	234.00		78.00
S5617	158	0		29	10	S5617_158_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	160	0		29	10	S5617_160_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	39.00	117.00									39.00				39.00	97.50		39.00	117.00		39.00
S5617	160	0		29	10	S5617_160_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	160	0		29	10	S5617_160_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	160	0		29	10	S5617_160_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	160	0		29	10	S5617_160_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	163	0		29	10	S5617_163_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	163	0		29	10	S5617_163_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00
S5617	163	0		29	10	S5617_163_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	163	0		29	10	S5617_163_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00
S5617	165	0		29	10	S5617_165_0	3	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	165	0		29	10	S5617_165_0	3	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	165	0		29	10	S5617_165_0	3	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00
S5617	165	0		29	10	S5617_165_0	3	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	165	0		29	10	S5617_165_0	3	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	47.00	141.00									47.00				47.00	117.50		47.00	141.00		47.00
S5617	168	0		29	10	S5617_168_0	2	1	2	1	Tier 1	010010		2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	2.50	7.50									2.50				2.50	6.25		2.50	7.50		2.50
S5617	168	0		29	10	S5617_168_0	2	4	2	1	Tier 4	010010		1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																					
S5617	168	0		29	10	S5617_168_0	2	2	2	1	Tier 2	010001		2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00									25.00				25.00	62.50		25.00	75.00		25.00
S5617	168	0		29	10	S5617_168_0	2	3	2	1	Tier 3	110000		2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	63.00	189.00									63.00				63.00	157.50		63.00	189.00		63.00
S5617	170	0		29	10	S5617_170_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00
S5617	170	0		29	10	S5617_170_0	2	2	4	1	Tier 2	010010	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	170	0		29	10	S5617_170_0	2	3	4	1	Tier 3	010001	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00
S5617	170	0		29	10	S5617_170_0	2	4	4	1	Tier 4	110000	1	2				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	2	Tier 4																						Tier 4	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00
S5617	170	0		29	10	S5617_170_0	2	5	4	1	Tier 5	000010	1	1				Tier 5	111000000001000110110	30	90									10			30	90		30	90			31	Tier 5	2	1	Tier 5	33	33									33				33	33		33	33		33	Tier 5																					
S5617	171	0		29	10	S5617_171_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	171	0		29	10	S5617_171_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	171	0		29	10	S5617_171_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	171	0		29	10	S5617_171_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	171	0		29	10	S5617_171_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	171	0		29	10	S5617_171_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	171	0		29	10	S5617_171_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	171	0		29	10	S5617_171_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	172	0		29	10	S5617_172_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	172	0		29	10	S5617_172_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	172	0		29	10	S5617_172_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	172	0		29	10	S5617_172_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	172	0		29	10	S5617_172_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	172	0		29	10	S5617_172_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	172	0		29	10	S5617_172_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	172	0		29	10	S5617_172_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	173	0		29	10	S5617_173_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	173	0		29	10	S5617_173_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	173	0		29	10	S5617_173_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	173	0		29	10	S5617_173_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	173	0		29	10	S5617_173_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	173	0		29	10	S5617_173_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	173	0		29	10	S5617_173_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	173	0		29	10	S5617_173_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	174	0		29	10	S5617_174_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	174	0		29	10	S5617_174_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	174	0		29	10	S5617_174_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	174	0		29	10	S5617_174_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	174	0		29	10	S5617_174_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	174	0		29	10	S5617_174_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	174	0		29	10	S5617_174_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	174	0		29	10	S5617_174_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	175	0		29	10	S5617_175_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	175	0		29	10	S5617_175_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	175	0		29	10	S5617_175_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	175	0		29	10	S5617_175_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	175	0		29	10	S5617_175_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	175	0		29	10	S5617_175_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	175	0		29	10	S5617_175_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	175	0		29	10	S5617_175_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	176	0		29	10	S5617_176_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	176	0		29	10	S5617_176_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	176	0		29	10	S5617_176_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	176	0		29	10	S5617_176_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	176	0		29	10	S5617_176_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	176	0		29	10	S5617_176_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	176	0		29	10	S5617_176_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	176	0		29	10	S5617_176_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	177	0		29	10	S5617_177_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	177	0		29	10	S5617_177_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	177	0		29	10	S5617_177_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	177	0		29	10	S5617_177_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	177	0		29	10	S5617_177_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	177	0		29	10	S5617_177_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	177	0		29	10	S5617_177_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	177	0		29	10	S5617_177_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	178	0		29	10	S5617_178_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	178	0		29	10	S5617_178_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	178	0		29	10	S5617_178_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	178	0		29	10	S5617_178_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	178	0		29	10	S5617_178_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	178	0		29	10	S5617_178_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	178	0		29	10	S5617_178_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	178	0		29	10	S5617_178_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	179	0		29	10	S5617_179_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	179	0		29	10	S5617_179_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	179	0		29	10	S5617_179_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	179	0		29	10	S5617_179_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	179	0		29	10	S5617_179_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	179	0		29	10	S5617_179_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	179	0		29	10	S5617_179_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	179	0		29	10	S5617_179_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	180	0		29	10	S5617_180_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	180	0		29	10	S5617_180_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	180	0		29	10	S5617_180_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	180	0		29	10	S5617_180_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	180	0		29	10	S5617_180_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	180	0		29	10	S5617_180_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	180	0		29	10	S5617_180_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	180	0		29	10	S5617_180_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	181	0		29	10	S5617_181_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	181	0		29	10	S5617_181_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	181	0		29	10	S5617_181_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	181	0		29	10	S5617_181_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	181	0		29	10	S5617_181_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	181	0		29	10	S5617_181_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	181	0		29	10	S5617_181_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	181	0		29	10	S5617_181_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	182	0		29	10	S5617_182_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	182	0		29	10	S5617_182_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	182	0		29	10	S5617_182_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	182	0		29	10	S5617_182_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	182	0		29	10	S5617_182_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	182	0		29	10	S5617_182_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	182	0		29	10	S5617_182_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	182	0		29	10	S5617_182_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	183	0		29	10	S5617_183_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	183	0		29	10	S5617_183_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	183	0		29	10	S5617_183_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	183	0		29	10	S5617_183_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	183	0		29	10	S5617_183_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	183	0		29	10	S5617_183_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	183	0		29	10	S5617_183_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	183	0		29	10	S5617_183_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	184	0		29	10	S5617_184_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	184	0		29	10	S5617_184_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	184	0		29	10	S5617_184_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	184	0		29	10	S5617_184_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	184	0		29	10	S5617_184_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	184	0		29	10	S5617_184_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	184	0		29	10	S5617_184_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	184	0		29	10	S5617_184_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	185	0		29	10	S5617_185_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	185	0		29	10	S5617_185_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	185	0		29	10	S5617_185_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	185	0		29	10	S5617_185_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	185	0		29	10	S5617_185_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	185	0		29	10	S5617_185_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	185	0		29	10	S5617_185_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	185	0		29	10	S5617_185_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	186	0		29	10	S5617_186_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	186	0		29	10	S5617_186_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	186	0		29	10	S5617_186_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	186	0		29	10	S5617_186_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	186	0		29	10	S5617_186_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	186	0		29	10	S5617_186_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	186	0		29	10	S5617_186_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	186	0		29	10	S5617_186_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	187	0		29	10	S5617_187_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	187	0		29	10	S5617_187_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	187	0		29	10	S5617_187_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	187	0		29	10	S5617_187_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	187	0		29	10	S5617_187_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	187	0		29	10	S5617_187_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	187	0		29	10	S5617_187_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	187	0		29	10	S5617_187_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	188	0		29	10	S5617_188_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	188	0		29	10	S5617_188_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	188	0		29	10	S5617_188_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	188	0		29	10	S5617_188_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	188	0		29	10	S5617_188_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	188	0		29	10	S5617_188_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	188	0		29	10	S5617_188_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	188	0		29	10	S5617_188_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	189	0		29	10	S5617_189_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	189	0		29	10	S5617_189_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	189	0		29	10	S5617_189_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	189	0		29	10	S5617_189_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	189	0		29	10	S5617_189_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	189	0		29	10	S5617_189_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	189	0		29	10	S5617_189_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	189	0		29	10	S5617_189_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	190	0		29	10	S5617_190_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	190	0		29	10	S5617_190_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	190	0		29	10	S5617_190_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	190	0		29	10	S5617_190_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	190	0		29	10	S5617_190_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	190	0		29	10	S5617_190_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	190	0		29	10	S5617_190_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	190	0		29	10	S5617_190_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	191	0		29	10	S5617_191_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	191	0		29	10	S5617_191_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	191	0		29	10	S5617_191_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	191	0		29	10	S5617_191_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	191	0		29	10	S5617_191_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	191	0		29	10	S5617_191_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	191	0		29	10	S5617_191_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	191	0		29	10	S5617_191_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	192	0		29	10	S5617_192_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	192	0		29	10	S5617_192_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	192	0		29	10	S5617_192_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	192	0		29	10	S5617_192_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	192	0		29	10	S5617_192_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	192	0		29	10	S5617_192_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	192	0		29	10	S5617_192_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	192	0		29	10	S5617_192_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	193	0		29	10	S5617_193_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	193	0		29	10	S5617_193_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	193	0		29	10	S5617_193_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	193	0		29	10	S5617_193_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	193	0		29	10	S5617_193_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	193	0		29	10	S5617_193_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	193	0		29	10	S5617_193_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	193	0		29	10	S5617_193_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	194	0		29	10	S5617_194_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	194	0		29	10	S5617_194_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	194	0		29	10	S5617_194_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	194	0		29	10	S5617_194_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	194	0		29	10	S5617_194_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	194	0		29	10	S5617_194_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	194	0		29	10	S5617_194_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	194	0		29	10	S5617_194_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	195	0		29	10	S5617_195_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	195	0		29	10	S5617_195_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	195	0		29	10	S5617_195_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	195	0		29	10	S5617_195_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	195	0		29	10	S5617_195_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	195	0		29	10	S5617_195_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	195	0		29	10	S5617_195_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	195	0		29	10	S5617_195_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	196	0		29	10	S5617_196_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	196	0		29	10	S5617_196_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	196	0		29	10	S5617_196_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	196	0		29	10	S5617_196_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	196	0		29	10	S5617_196_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	196	0		29	10	S5617_196_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	196	0		29	10	S5617_196_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	196	0		29	10	S5617_196_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	197	0		29	10	S5617_197_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	197	0		29	10	S5617_197_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	197	0		29	10	S5617_197_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	197	0		29	10	S5617_197_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	197	0		29	10	S5617_197_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	197	0		29	10	S5617_197_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	197	0		29	10	S5617_197_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	197	0		29	10	S5617_197_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	198	0		29	10	S5617_198_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	198	0		29	10	S5617_198_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	198	0		29	10	S5617_198_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	198	0		29	10	S5617_198_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	198	0		29	10	S5617_198_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	198	0		29	10	S5617_198_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	198	0		29	10	S5617_198_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	198	0		29	10	S5617_198_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	199	0		29	10	S5617_199_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	199	0		29	10	S5617_199_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	199	0		29	10	S5617_199_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	199	0		29	10	S5617_199_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	199	0		29	10	S5617_199_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	199	0		29	10	S5617_199_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	199	0		29	10	S5617_199_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	199	0		29	10	S5617_199_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	200	0		29	10	S5617_200_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	200	0		29	10	S5617_200_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	200	0		29	10	S5617_200_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	200	0		29	10	S5617_200_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	200	0		29	10	S5617_200_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	200	0		29	10	S5617_200_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	200	0		29	10	S5617_200_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	200	0		29	10	S5617_200_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	201	0		29	10	S5617_201_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	201	0		29	10	S5617_201_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	201	0		29	10	S5617_201_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	201	0		29	10	S5617_201_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	201	0		29	10	S5617_201_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	201	0		29	10	S5617_201_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	201	0		29	10	S5617_201_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	201	0		29	10	S5617_201_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	202	0		29	10	S5617_202_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	202	0		29	10	S5617_202_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	202	0		29	10	S5617_202_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	202	0		29	10	S5617_202_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	202	0		29	10	S5617_202_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	202	0		29	10	S5617_202_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	202	0		29	10	S5617_202_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	202	0		29	10	S5617_202_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	203	0		29	10	S5617_203_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	203	0		29	10	S5617_203_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5617	203	0		29	10	S5617_203_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	203	0		29	10	S5617_203_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	203	0		29	10	S5617_203_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	203	0		29	10	S5617_203_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	203	0		29	10	S5617_203_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	203	0		29	10	S5617_203_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	204	0		29	10	S5617_204_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001000110110	30	90									10			30	90		30	90			31	Tier 4	2	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																					
S5617	204	0		29	10	S5617_204_0	2	1	4	3	Tier 1	010010	1	2	1	00001000	2	Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	1	Tier 1	25	25									25				25	25		26	26		25	Tier 1																					
S5617	204	0		29	10	S5617_204_0	2	2	4	3	Tier 2	010001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5617	204	0		29	10	S5617_204_0	2	3	4	3	Tier 3	110000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5617	204	0		29	10	S5617_204_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5617	204	0		29	10	S5617_204_0	2	3	4	1	Tier 3	110000	1	2				Tier 3	111000000001000110110	30	90									10			30	90		30	90			31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00
S5617	204	0		29	10	S5617_204_0	2	2	4	1	Tier 2	010001	1	2				Tier 2	111000000001000110110	30	90									10			30	90		30	90			31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00
S5617	204	0		29	10	S5617_204_0	2	1	4	1	Tier 1	010010	1	2				Tier 1	111000000001000110110	30	90									10			30	90		30	90			31	Tier 1	2	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00
S5644	004	0		29	10	S5644_004_0	4	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	004	0		29	10	S5644_004_0	4	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	004	0		29	10	S5644_004_0	4	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	004	0		29	10	S5644_004_0	4	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	005	0		29	10	S5644_005_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.50	19.50	13.00							6.50						0.00			19.50		6.50
S5644	005	0		29	10	S5644_005_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	005	0		29	10	S5644_005_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	005	0		29	10	S5644_005_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	012	0		29	10	S5644_012_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	012	0		29	10	S5644_012_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	012	0		29	10	S5644_012_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	012	0		29	10	S5644_012_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	045	0		29	10	S5644_045_0	4	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	045	0		29	10	S5644_045_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	045	0		29	10	S5644_045_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	045	0		29	10	S5644_045_0	4	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	047	0		29	10	S5644_047_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	047	0		29	10	S5644_047_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	047	0		29	10	S5644_047_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	047	0		29	10	S5644_047_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	048	0		29	10	S5644_048_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00						0.00			12.00		4.00
S5644	048	0		29	10	S5644_048_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	048	0		29	10	S5644_048_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	048	0		29	10	S5644_048_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	049	0		29	10	S5644_049_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	049	0		29	10	S5644_049_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	049	0		29	10	S5644_049_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	049	0		29	10	S5644_049_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	050	0		29	10	S5644_050_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	050	0		29	10	S5644_050_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	050	0		29	10	S5644_050_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	050	0		29	10	S5644_050_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	051	0		29	10	S5644_051_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	051	0		29	10	S5644_051_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	051	0		29	10	S5644_051_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	051	0		29	10	S5644_051_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	052	0		29	10	S5644_052_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	052	0		29	10	S5644_052_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	052	0		29	10	S5644_052_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	052	0		29	10	S5644_052_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	053	0		29	10	S5644_053_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	053	0		29	10	S5644_053_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	053	0		29	10	S5644_053_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	053	0		29	10	S5644_053_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	054	0		29	10	S5644_054_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	054	0		29	10	S5644_054_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	054	0		29	10	S5644_054_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	054	0		29	10	S5644_054_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	055	0		29	10	S5644_055_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	055	0		29	10	S5644_055_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	055	0		29	10	S5644_055_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	055	0		29	10	S5644_055_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	056	0		29	10	S5644_056_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	056	0		29	10	S5644_056_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	056	0		29	10	S5644_056_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	056	0		29	10	S5644_056_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	057	0		29	10	S5644_057_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	057	0		29	10	S5644_057_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	057	0		29	10	S5644_057_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	057	0		29	10	S5644_057_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	058	0		29	10	S5644_058_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	058	0		29	10	S5644_058_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	058	0		29	10	S5644_058_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	058	0		29	10	S5644_058_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	059	0		29	10	S5644_059_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	059	0		29	10	S5644_059_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	059	0		29	10	S5644_059_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	059	0		29	10	S5644_059_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	060	0		29	10	S5644_060_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.25	12.75	8.50							4.25						0.00			12.75		4.25
S5644	060	0		29	10	S5644_060_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	060	0		29	10	S5644_060_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	060	0		29	10	S5644_060_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	061	0		29	10	S5644_061_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	061	0		29	10	S5644_061_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	061	0		29	10	S5644_061_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	061	0		29	10	S5644_061_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	062	0		29	10	S5644_062_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	062	0		29	10	S5644_062_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	062	0		29	10	S5644_062_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	062	0		29	10	S5644_062_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	063	0		29	10	S5644_063_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	063	0		29	10	S5644_063_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	063	0		29	10	S5644_063_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	063	0		29	10	S5644_063_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	064	0		29	10	S5644_064_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.25	12.75	8.50							4.25						0.00			12.75		4.25
S5644	064	0		29	10	S5644_064_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	064	0		29	10	S5644_064_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	064	0		29	10	S5644_064_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	065	0		29	10	S5644_065_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	065	0		29	10	S5644_065_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	065	0		29	10	S5644_065_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	065	0		29	10	S5644_065_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	067	0		29	10	S5644_067_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	067	0		29	10	S5644_067_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	067	0		29	10	S5644_067_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	067	0		29	10	S5644_067_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	068	0		29	10	S5644_068_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	068	0		29	10	S5644_068_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	068	0		29	10	S5644_068_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	068	0		29	10	S5644_068_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	071	0		29	10	S5644_071_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	071	0		29	10	S5644_071_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	071	0		29	10	S5644_071_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	071	0		29	10	S5644_071_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	072	0		29	10	S5644_072_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	072	0		29	10	S5644_072_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	072	0		29	10	S5644_072_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	072	0		29	10	S5644_072_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	073	0		29	10	S5644_073_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	073	0		29	10	S5644_073_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	073	0		29	10	S5644_073_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	073	0		29	10	S5644_073_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	074	0		29	10	S5644_074_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	074	0		29	10	S5644_074_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	074	0		29	10	S5644_074_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	074	0		29	10	S5644_074_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	075	0		29	10	S5644_075_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	075	0		29	10	S5644_075_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	075	0		29	10	S5644_075_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	075	0		29	10	S5644_075_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	076	0		29	10	S5644_076_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	076	0		29	10	S5644_076_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	076	0		29	10	S5644_076_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	076	0		29	10	S5644_076_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	078	0		29	10	S5644_078_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	078	0		29	10	S5644_078_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	078	0		29	10	S5644_078_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	078	0		29	10	S5644_078_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	079	0		29	10	S5644_079_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	079	0		29	10	S5644_079_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	079	0		29	10	S5644_079_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	079	0		29	10	S5644_079_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	080	0		29	10	S5644_080_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	080	0		29	10	S5644_080_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	080	0		29	10	S5644_080_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	080	0		29	10	S5644_080_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	081	0		29	10	S5644_081_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	081	0		29	10	S5644_081_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	081	0		29	10	S5644_081_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	081	0		29	10	S5644_081_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	082	0		29	10	S5644_082_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	082	0		29	10	S5644_082_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	082	0		29	10	S5644_082_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	082	0		29	10	S5644_082_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	083	0		29	10	S5644_083_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	083	0		29	10	S5644_083_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	083	0		29	10	S5644_083_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	083	0		29	10	S5644_083_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	084	0		29	10	S5644_084_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	084	0		29	10	S5644_084_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	084	0		29	10	S5644_084_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	084	0		29	10	S5644_084_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	085	0		29	10	S5644_085_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	085	0		29	10	S5644_085_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	085	0		29	10	S5644_085_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	085	0		29	10	S5644_085_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	087	0		29	10	S5644_087_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	087	0		29	10	S5644_087_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	087	0		29	10	S5644_087_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	087	0		29	10	S5644_087_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	174	0		29	10	S5644_174_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	174	0		29	10	S5644_174_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	174	0		29	10	S5644_174_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	174	0		29	10	S5644_174_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	175	0		29	10	S5644_175_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	175	0		29	10	S5644_175_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	175	0		29	10	S5644_175_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	175	0		29	10	S5644_175_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	176	0		29	10	S5644_176_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	176	0		29	10	S5644_176_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	176	0		29	10	S5644_176_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	176	0		29	10	S5644_176_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	177	0		29	10	S5644_177_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.25	12.75	8.50							4.25						0.00			12.75		4.25
S5644	177	0		29	10	S5644_177_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	177	0		29	10	S5644_177_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	177	0		29	10	S5644_177_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	178	0		29	10	S5644_178_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	178	0		29	10	S5644_178_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	178	0		29	10	S5644_178_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	178	0		29	10	S5644_178_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	179	0		29	10	S5644_179_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	179	0		29	10	S5644_179_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	179	0		29	10	S5644_179_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	179	0		29	10	S5644_179_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	180	0		29	10	S5644_180_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	180	0		29	10	S5644_180_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	180	0		29	10	S5644_180_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	180	0		29	10	S5644_180_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	181	0		29	10	S5644_181_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	181	0		29	10	S5644_181_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.50	13.50	9.00							4.50						0.00			13.50		4.50
S5644	181	0		29	10	S5644_181_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	181	0		29	10	S5644_181_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	182	0		29	10	S5644_182_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	182	0		29	10	S5644_182_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	182	0		29	10	S5644_182_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	182	0		29	10	S5644_182_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	183	0		29	10	S5644_183_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.25	12.75	8.50							4.25						0.00			12.75		4.25
S5644	183	0		29	10	S5644_183_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	183	0		29	10	S5644_183_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	183	0		29	10	S5644_183_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	184	0		29	10	S5644_184_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	184	0		29	10	S5644_184_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	184	0		29	10	S5644_184_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	184	0		29	10	S5644_184_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	185	0		29	10	S5644_185_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	185	0		29	10	S5644_185_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	185	0		29	10	S5644_185_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	185	0		29	10	S5644_185_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	186	0		29	10	S5644_186_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	186	0		29	10	S5644_186_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	186	0		29	10	S5644_186_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	186	0		29	10	S5644_186_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	187	0		29	10	S5644_187_0	3	4	4	1	Non-Preferred	100100	1	2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	187	0		29	10	S5644_187_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	35	35	35							35						40			35		35	Preferred Brand																					
S5644	187	0		29	10	S5644_187_0	3	3	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5644	187	0		29	10	S5644_187_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	188	0		29	10	S5644_188_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	188	0		29	10	S5644_188_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	188	0		29	10	S5644_188_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	188	0		29	10	S5644_188_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	189	0		29	10	S5644_189_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	189	0		29	10	S5644_189_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	189	0		29	10	S5644_189_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	189	0		29	10	S5644_189_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	190	0		29	10	S5644_190_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	190	0		29	10	S5644_190_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	190	0		29	10	S5644_190_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	190	0		29	10	S5644_190_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	191	0		29	10	S5644_191_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	191	0		29	10	S5644_191_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	191	0		29	10	S5644_191_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	191	0		29	10	S5644_191_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.25	18.75	12.50							6.25						0.00			18.75		6.25
S5644	192	0		29	10	S5644_192_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	192	0		29	10	S5644_192_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	192	0		29	10	S5644_192_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.25	18.75	12.50							6.25						0.00			18.75		6.25
S5644	192	0		29	10	S5644_192_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	193	0		29	10	S5644_193_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	193	0		29	10	S5644_193_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	193	0		29	10	S5644_193_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	193	0		29	10	S5644_193_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	194	0		29	10	S5644_194_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	194	0		29	10	S5644_194_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	194	0		29	10	S5644_194_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	194	0		29	10	S5644_194_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.75	14.25	9.50							4.75						0.00			14.25		4.75
S5644	195	0		29	10	S5644_195_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	195	0		29	10	S5644_195_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	195	0		29	10	S5644_195_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	195	0		29	10	S5644_195_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	196	0		29	10	S5644_196_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	196	0		29	10	S5644_196_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	196	0		29	10	S5644_196_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	196	0		29	10	S5644_196_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						0.00			15.00		5.00
S5644	197	0		29	10	S5644_197_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	197	0		29	10	S5644_197_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	197	0		29	10	S5644_197_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	197	0		29	10	S5644_197_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	198	0		29	10	S5644_198_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	198	0		29	10	S5644_198_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	198	0		29	10	S5644_198_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	198	0		29	10	S5644_198_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.50	16.50	11.00							5.50						0.00			16.50		5.50
S5644	199	0		29	10	S5644_199_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	199	0		29	10	S5644_199_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	199	0		29	10	S5644_199_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	199	0		29	10	S5644_199_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.25	18.75	12.50							6.25						0.00			18.75		6.25
S5644	200	0		29	10	S5644_200_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	200	0		29	10	S5644_200_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	200	0		29	10	S5644_200_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	200	0		29	10	S5644_200_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5644	201	0		29	10	S5644_201_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000010010	30	90	60							30					90			90			31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.25	15.75	10.50							5.25						0.00			15.75		5.25
S5644	201	0		29	10	S5644_201_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000010010	30	90	60							30					90			90			31	Preferred Brand	1	1	Preferred Brand	25	25	25							25						30			25		25	Preferred Brand																					
S5644	201	0		29	10	S5644_201_0	3	3	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				31	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5644	201	0		29	10	S5644_201_0	3	4	2	1	Non-Preferred	100100		2				Non-Preferred	111100000010000010010	30	90	60							30					90			90			31	Non-Preferred	1	1	Non-Preferred	45	45	45							45						45			45		45	Non-Preferred																					
S5660	001	0		29	10	S5660_001_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	001	0		29	10	S5660_001_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	001	0		29	10	S5660_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	001	0		29	10	S5660_001_0	5	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	003	0		29	10	S5660_003_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	003	0		29	10	S5660_003_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	003	0		29	10	S5660_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	003	0		29	10	S5660_003_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	004	0		29	10	S5660_004_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	004	0		29	10	S5660_004_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	004	0		29	10	S5660_004_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	004	0		29	10	S5660_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	005	0		29	10	S5660_005_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	005	0		29	10	S5660_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	005	0		29	10	S5660_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	005	0		29	10	S5660_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	006	0		29	10	S5660_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	006	0		29	10	S5660_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	006	0		29	10	S5660_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	006	0		29	10	S5660_006_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	007	0		29	10	S5660_007_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	007	0		29	10	S5660_007_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	007	0		29	10	S5660_007_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	007	0		29	10	S5660_007_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	008	0		29	10	S5660_008_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	008	0		29	10	S5660_008_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	008	0		29	10	S5660_008_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	008	0		29	10	S5660_008_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	009	0		29	10	S5660_009_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	009	0		29	10	S5660_009_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	009	0		29	10	S5660_009_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	009	0		29	10	S5660_009_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	010	0		29	10	S5660_010_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	010	0		29	10	S5660_010_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	010	0		29	10	S5660_010_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	010	0		29	10	S5660_010_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	012	0		29	10	S5660_012_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	012	0		29	10	S5660_012_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	012	0		29	10	S5660_012_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	012	0		29	10	S5660_012_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	013	0		29	10	S5660_013_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	013	0		29	10	S5660_013_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	013	0		29	10	S5660_013_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	013	0		29	10	S5660_013_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	014	0		29	10	S5660_014_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	014	0		29	10	S5660_014_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	014	0		29	10	S5660_014_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	014	0		29	10	S5660_014_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	015	0		29	10	S5660_015_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	015	0		29	10	S5660_015_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	015	0		29	10	S5660_015_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	015	0		29	10	S5660_015_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	016	0		29	10	S5660_016_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	016	0		29	10	S5660_016_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	016	0		29	10	S5660_016_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	016	0		29	10	S5660_016_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	017	0		29	10	S5660_017_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	017	0		29	10	S5660_017_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	017	0		29	10	S5660_017_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	017	0		29	10	S5660_017_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	018	0		29	10	S5660_018_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	018	0		29	10	S5660_018_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	018	0		29	10	S5660_018_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	018	0		29	10	S5660_018_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	019	0		29	10	S5660_019_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	019	0		29	10	S5660_019_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	019	0		29	10	S5660_019_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	019	0		29	10	S5660_019_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	020	0		29	10	S5660_020_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	020	0		29	10	S5660_020_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	020	0		29	10	S5660_020_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	020	0		29	10	S5660_020_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	021	0		29	10	S5660_021_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	021	0		29	10	S5660_021_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	021	0		29	10	S5660_021_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	021	0		29	10	S5660_021_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	022	0		29	10	S5660_022_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	022	0		29	10	S5660_022_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	022	0		29	10	S5660_022_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	022	0		29	10	S5660_022_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	023	0		29	10	S5660_023_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	023	0		29	10	S5660_023_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	023	0		29	10	S5660_023_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	023	0		29	10	S5660_023_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	024	0		29	10	S5660_024_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	024	0		29	10	S5660_024_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	024	0		29	10	S5660_024_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	024	0		29	10	S5660_024_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	025	0		29	10	S5660_025_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	025	0		29	10	S5660_025_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	025	0		29	10	S5660_025_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	025	0		29	10	S5660_025_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	026	0		29	10	S5660_026_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	026	0		29	10	S5660_026_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	026	0		29	10	S5660_026_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	026	0		29	10	S5660_026_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	027	0		29	10	S5660_027_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	027	0		29	10	S5660_027_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	027	0		29	10	S5660_027_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	027	0		29	10	S5660_027_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	028	0		29	10	S5660_028_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	028	0		29	10	S5660_028_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	028	0		29	10	S5660_028_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	028	0		29	10	S5660_028_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	029	0		29	10	S5660_029_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	029	0		29	10	S5660_029_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	029	0		29	10	S5660_029_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	029	0		29	10	S5660_029_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	030	0		29	10	S5660_030_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	030	0		29	10	S5660_030_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	030	0		29	10	S5660_030_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	030	0		29	10	S5660_030_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	031	0		29	10	S5660_031_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	031	0		29	10	S5660_031_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	031	0		29	10	S5660_031_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	031	0		29	10	S5660_031_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	032	0		29	10	S5660_032_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	032	0		29	10	S5660_032_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	032	0		29	10	S5660_032_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	032	0		29	10	S5660_032_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	033	0		29	10	S5660_033_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	033	0		29	10	S5660_033_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	033	0		29	10	S5660_033_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	033	0		29	10	S5660_033_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	034	0		29	10	S5660_034_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	034	0		29	10	S5660_034_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	034	0		29	10	S5660_034_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	034	0		29	10	S5660_034_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	035	0		29	10	S5660_035_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	035	0		29	10	S5660_035_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	035	0		29	10	S5660_035_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			95.00								38.00
S5660	035	0		29	10	S5660_035_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	103	0		29	10	S5660_103_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	103	0		29	10	S5660_103_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	103	0		29	10	S5660_103_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	103	0		29	10	S5660_103_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	104	0		29	10	S5660_104_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	104	0		29	10	S5660_104_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	104	0		29	10	S5660_104_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	104	0		29	10	S5660_104_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	105	0		29	10	S5660_105_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	105	0		29	10	S5660_105_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	105	0		29	10	S5660_105_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	105	0		29	10	S5660_105_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	106	0		29	10	S5660_106_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	106	0		29	10	S5660_106_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	106	0		29	10	S5660_106_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	106	0		29	10	S5660_106_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	107	0		29	10	S5660_107_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	107	0		29	10	S5660_107_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	107	0		29	10	S5660_107_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	107	0		29	10	S5660_107_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	108	0		29	10	S5660_108_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	52	52								52			52								52	Non-Preferred Brand																					
S5660	108	0		29	10	S5660_108_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	108	0		29	10	S5660_108_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	108	0		29	10	S5660_108_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	109	0		29	10	S5660_109_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	109	0		29	10	S5660_109_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	109	0		29	10	S5660_109_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	109	0		29	10	S5660_109_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	110	0		29	10	S5660_110_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	110	0		29	10	S5660_110_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	110	0		29	10	S5660_110_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	110	0		29	10	S5660_110_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	111	0		29	10	S5660_111_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	111	0		29	10	S5660_111_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	111	0		29	10	S5660_111_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	111	0		29	10	S5660_111_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	112	0		29	10	S5660_112_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	112	0		29	10	S5660_112_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	112	0		29	10	S5660_112_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	112	0		29	10	S5660_112_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	113	0		29	10	S5660_113_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	113	0		29	10	S5660_113_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	113	0		29	10	S5660_113_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	113	0		29	10	S5660_113_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	114	0		29	10	S5660_114_0	3	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	114	0		29	10	S5660_114_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	114	0		29	10	S5660_114_0	3	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	114	0		29	10	S5660_114_0	3	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	115	0		29	10	S5660_115_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	115	0		29	10	S5660_115_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	115	0		29	10	S5660_115_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	115	0		29	10	S5660_115_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	116	0		29	10	S5660_116_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	116	0		29	10	S5660_116_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	116	0		29	10	S5660_116_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	116	0		29	10	S5660_116_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	117	0		29	10	S5660_117_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	117	0		29	10	S5660_117_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	117	0		29	10	S5660_117_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	117	0		29	10	S5660_117_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	118	0		29	10	S5660_118_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	118	0		29	10	S5660_118_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	118	0		29	10	S5660_118_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	118	0		29	10	S5660_118_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	119	0		29	10	S5660_119_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	119	0		29	10	S5660_119_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	119	0		29	10	S5660_119_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	119	0		29	10	S5660_119_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	120	0		29	10	S5660_120_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	120	0		29	10	S5660_120_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	120	0		29	10	S5660_120_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	120	0		29	10	S5660_120_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	121	0		29	10	S5660_121_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	121	0		29	10	S5660_121_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	121	0		29	10	S5660_121_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	121	0		29	10	S5660_121_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
S5660	122	0		29	10	S5660_122_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	122	0		29	10	S5660_122_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	122	0		29	10	S5660_122_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	122	0		29	10	S5660_122_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	123	0		29	10	S5660_123_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	123	0		29	10	S5660_123_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	123	0		29	10	S5660_123_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	123	0		29	10	S5660_123_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	124	0		29	10	S5660_124_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	124	0		29	10	S5660_124_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	124	0		29	10	S5660_124_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	124	0		29	10	S5660_124_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	125	0		29	10	S5660_125_0	3	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	125	0		29	10	S5660_125_0	3	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	125	0		29	10	S5660_125_0	3	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	125	0		29	10	S5660_125_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	126	0		29	10	S5660_126_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	126	0		29	10	S5660_126_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	126	0		29	10	S5660_126_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	126	0		29	10	S5660_126_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	127	0		29	10	S5660_127_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	127	0		29	10	S5660_127_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	127	0		29	10	S5660_127_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	127	0		29	10	S5660_127_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	128	0		29	10	S5660_128_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	128	0		29	10	S5660_128_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	128	0		29	10	S5660_128_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	128	0		29	10	S5660_128_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	129	0		29	10	S5660_129_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	129	0		29	10	S5660_129_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	129	0		29	10	S5660_129_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	52	52								52			52								52	Non-Preferred Brand																					
S5660	129	0		29	10	S5660_129_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	130	0		29	10	S5660_130_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	130	0		29	10	S5660_130_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	130	0		29	10	S5660_130_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	130	0		29	10	S5660_130_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	131	0		29	10	S5660_131_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	131	0		29	10	S5660_131_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	131	0		29	10	S5660_131_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	131	0		29	10	S5660_131_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	132	0		29	10	S5660_132_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	132	0		29	10	S5660_132_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	132	0		29	10	S5660_132_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	132	0		29	10	S5660_132_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	133	0		29	10	S5660_133_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	133	0		29	10	S5660_133_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	133	0		29	10	S5660_133_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	133	0		29	10	S5660_133_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	134	0		29	10	S5660_134_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	134	0		29	10	S5660_134_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	134	0		29	10	S5660_134_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	134	0		29	10	S5660_134_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	135	0		29	10	S5660_135_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	135	0		29	10	S5660_135_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	135	0		29	10	S5660_135_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	135	0		29	10	S5660_135_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	136	0		29	10	S5660_136_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	136	0		29	10	S5660_136_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	136	0		29	10	S5660_136_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	136	0		29	10	S5660_136_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	137	0		29	10	S5660_137_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5660	137	0		29	10	S5660_137_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5660	137	0		29	10	S5660_137_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5660	137	0		29	10	S5660_137_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5660	172	0		29	10	S5660_172_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	172	0		29	10	S5660_172_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	172	0		29	10	S5660_172_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	172	0		29	10	S5660_172_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	172	0		29	10	S5660_172_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	172	0		29	10	S5660_172_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	172	0		29	10	S5660_172_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	172	0		29	10	S5660_172_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	173	0		29	10	S5660_173_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	173	0		29	10	S5660_173_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	173	0		29	10	S5660_173_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	173	0		29	10	S5660_173_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	173	0		29	10	S5660_173_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	173	0		29	10	S5660_173_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	173	0		29	10	S5660_173_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	173	0		29	10	S5660_173_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	174	0		29	10	S5660_174_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	174	0		29	10	S5660_174_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	174	0		29	10	S5660_174_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	174	0		29	10	S5660_174_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	174	0		29	10	S5660_174_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	174	0		29	10	S5660_174_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	174	0		29	10	S5660_174_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	174	0		29	10	S5660_174_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	175	0		29	10	S5660_175_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	175	0		29	10	S5660_175_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	175	0		29	10	S5660_175_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	175	0		29	10	S5660_175_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	175	0		29	10	S5660_175_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	175	0		29	10	S5660_175_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	175	0		29	10	S5660_175_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	175	0		29	10	S5660_175_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	176	0		29	10	S5660_176_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	176	0		29	10	S5660_176_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	176	0		29	10	S5660_176_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	176	0		29	10	S5660_176_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	176	0		29	10	S5660_176_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	176	0		29	10	S5660_176_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	176	0		29	10	S5660_176_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	176	0		29	10	S5660_176_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	177	0		29	10	S5660_177_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	177	0		29	10	S5660_177_0	4	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	177	0		29	10	S5660_177_0	4	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	177	0		29	10	S5660_177_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	177	0		29	10	S5660_177_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	177	0		29	10	S5660_177_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	177	0		29	10	S5660_177_0	4	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	177	0		29	10	S5660_177_0	4	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	178	0		29	10	S5660_178_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	178	0		29	10	S5660_178_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	178	0		29	10	S5660_178_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	178	0		29	10	S5660_178_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	178	0		29	10	S5660_178_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	178	0		29	10	S5660_178_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	178	0		29	10	S5660_178_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	178	0		29	10	S5660_178_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	179	0		29	10	S5660_179_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	179	0		29	10	S5660_179_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	179	0		29	10	S5660_179_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	179	0		29	10	S5660_179_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	179	0		29	10	S5660_179_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	179	0		29	10	S5660_179_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	179	0		29	10	S5660_179_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	179	0		29	10	S5660_179_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	180	0		29	10	S5660_180_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	180	0		29	10	S5660_180_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	180	0		29	10	S5660_180_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	180	0		29	10	S5660_180_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	180	0		29	10	S5660_180_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	180	0		29	10	S5660_180_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	180	0		29	10	S5660_180_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	180	0		29	10	S5660_180_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	181	0		29	10	S5660_181_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	181	0		29	10	S5660_181_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	181	0		29	10	S5660_181_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	181	0		29	10	S5660_181_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	181	0		29	10	S5660_181_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	181	0		29	10	S5660_181_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	181	0		29	10	S5660_181_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	181	0		29	10	S5660_181_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	182	0		29	10	S5660_182_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	182	0		29	10	S5660_182_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	182	0		29	10	S5660_182_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	182	0		29	10	S5660_182_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	182	0		29	10	S5660_182_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	182	0		29	10	S5660_182_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	182	0		29	10	S5660_182_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	182	0		29	10	S5660_182_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	183	0		29	10	S5660_183_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	183	0		29	10	S5660_183_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	183	0		29	10	S5660_183_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	183	0		29	10	S5660_183_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	183	0		29	10	S5660_183_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	183	0		29	10	S5660_183_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	183	0		29	10	S5660_183_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	183	0		29	10	S5660_183_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	184	0		29	10	S5660_184_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	184	0		29	10	S5660_184_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	184	0		29	10	S5660_184_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	184	0		29	10	S5660_184_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	184	0		29	10	S5660_184_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	184	0		29	10	S5660_184_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	184	0		29	10	S5660_184_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	184	0		29	10	S5660_184_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	185	0		29	10	S5660_185_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	185	0		29	10	S5660_185_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	185	0		29	10	S5660_185_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	185	0		29	10	S5660_185_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	185	0		29	10	S5660_185_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	185	0		29	10	S5660_185_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	185	0		29	10	S5660_185_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	185	0		29	10	S5660_185_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	186	0		29	10	S5660_186_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	186	0		29	10	S5660_186_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	186	0		29	10	S5660_186_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	186	0		29	10	S5660_186_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	186	0		29	10	S5660_186_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	186	0		29	10	S5660_186_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	186	0		29	10	S5660_186_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	186	0		29	10	S5660_186_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	187	0		29	10	S5660_187_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	187	0		29	10	S5660_187_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	187	0		29	10	S5660_187_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	187	0		29	10	S5660_187_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	187	0		29	10	S5660_187_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	187	0		29	10	S5660_187_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	187	0		29	10	S5660_187_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	187	0		29	10	S5660_187_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	188	0		29	10	S5660_188_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	188	0		29	10	S5660_188_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	188	0		29	10	S5660_188_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	188	0		29	10	S5660_188_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	188	0		29	10	S5660_188_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	188	0		29	10	S5660_188_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	188	0		29	10	S5660_188_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	188	0		29	10	S5660_188_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	189	0		29	10	S5660_189_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	189	0		29	10	S5660_189_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	189	0		29	10	S5660_189_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	189	0		29	10	S5660_189_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	189	0		29	10	S5660_189_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	189	0		29	10	S5660_189_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	189	0		29	10	S5660_189_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	189	0		29	10	S5660_189_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	190	0		29	10	S5660_190_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	190	0		29	10	S5660_190_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	190	0		29	10	S5660_190_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	190	0		29	10	S5660_190_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	190	0		29	10	S5660_190_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	190	0		29	10	S5660_190_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	190	0		29	10	S5660_190_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	190	0		29	10	S5660_190_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	191	0		29	10	S5660_191_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	191	0		29	10	S5660_191_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	191	0		29	10	S5660_191_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	191	0		29	10	S5660_191_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	191	0		29	10	S5660_191_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	191	0		29	10	S5660_191_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	191	0		29	10	S5660_191_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	191	0		29	10	S5660_191_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	192	0		29	10	S5660_192_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	192	0		29	10	S5660_192_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	192	0		29	10	S5660_192_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	192	0		29	10	S5660_192_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	192	0		29	10	S5660_192_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	192	0		29	10	S5660_192_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	192	0		29	10	S5660_192_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	192	0		29	10	S5660_192_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	193	0		29	10	S5660_193_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	193	0		29	10	S5660_193_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	193	0		29	10	S5660_193_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	193	0		29	10	S5660_193_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	193	0		29	10	S5660_193_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	193	0		29	10	S5660_193_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	193	0		29	10	S5660_193_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	193	0		29	10	S5660_193_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	194	0		29	10	S5660_194_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	194	0		29	10	S5660_194_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	194	0		29	10	S5660_194_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	194	0		29	10	S5660_194_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	194	0		29	10	S5660_194_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	194	0		29	10	S5660_194_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	194	0		29	10	S5660_194_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	194	0		29	10	S5660_194_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	195	0		29	10	S5660_195_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	195	0		29	10	S5660_195_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	195	0		29	10	S5660_195_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	195	0		29	10	S5660_195_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	195	0		29	10	S5660_195_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	195	0		29	10	S5660_195_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	195	0		29	10	S5660_195_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	195	0		29	10	S5660_195_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	196	0		29	10	S5660_196_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	196	0		29	10	S5660_196_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	196	0		29	10	S5660_196_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	196	0		29	10	S5660_196_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	196	0		29	10	S5660_196_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	196	0		29	10	S5660_196_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	196	0		29	10	S5660_196_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	196	0		29	10	S5660_196_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	197	0		29	10	S5660_197_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	197	0		29	10	S5660_197_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	197	0		29	10	S5660_197_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	197	0		29	10	S5660_197_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	197	0		29	10	S5660_197_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	197	0		29	10	S5660_197_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	197	0		29	10	S5660_197_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	197	0		29	10	S5660_197_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	198	0		29	10	S5660_198_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	198	0		29	10	S5660_198_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	198	0		29	10	S5660_198_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	198	0		29	10	S5660_198_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	198	0		29	10	S5660_198_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	198	0		29	10	S5660_198_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	198	0		29	10	S5660_198_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	198	0		29	10	S5660_198_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	199	0		29	10	S5660_199_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	199	0		29	10	S5660_199_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	199	0		29	10	S5660_199_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	199	0		29	10	S5660_199_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	199	0		29	10	S5660_199_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	199	0		29	10	S5660_199_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	199	0		29	10	S5660_199_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	199	0		29	10	S5660_199_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	200	0		29	10	S5660_200_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	200	0		29	10	S5660_200_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	200	0		29	10	S5660_200_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	200	0		29	10	S5660_200_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	200	0		29	10	S5660_200_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	200	0		29	10	S5660_200_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	200	0		29	10	S5660_200_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	200	0		29	10	S5660_200_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	201	0		29	10	S5660_201_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	201	0		29	10	S5660_201_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	201	0		29	10	S5660_201_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	201	0		29	10	S5660_201_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	201	0		29	10	S5660_201_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	201	0		29	10	S5660_201_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	201	0		29	10	S5660_201_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	201	0		29	10	S5660_201_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	202	0		29	10	S5660_202_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	202	0		29	10	S5660_202_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	202	0		29	10	S5660_202_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	202	0		29	10	S5660_202_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	202	0		29	10	S5660_202_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	202	0		29	10	S5660_202_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	202	0		29	10	S5660_202_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	202	0		29	10	S5660_202_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	203	0		29	10	S5660_203_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	203	0		29	10	S5660_203_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	203	0		29	10	S5660_203_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	203	0		29	10	S5660_203_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	203	0		29	10	S5660_203_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	203	0		29	10	S5660_203_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	203	0		29	10	S5660_203_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	203	0		29	10	S5660_203_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	204	0		29	10	S5660_204_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	204	0		29	10	S5660_204_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	204	0		29	10	S5660_204_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	204	0		29	10	S5660_204_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5660	204	0		29	10	S5660_204_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	204	0		29	10	S5660_204_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	204	0		29	10	S5660_204_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	204	0		29	10	S5660_204_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	205	0		29	10	S5660_205_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5660	205	0		29	10	S5660_205_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5660	205	0		29	10	S5660_205_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	205	0		29	10	S5660_205_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5660	205	0		29	10	S5660_205_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5660	205	0		29	10	S5660_205_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5660	205	0		29	10	S5660_205_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5660	205	0		29	10	S5660_205_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5670	027	0		29	10	S5670_027_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	027	0		29	10	S5670_027_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	027	0		29	10	S5670_027_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	027	0		29	10	S5670_027_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	028	0		29	10	S5670_028_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	028	0		29	10	S5670_028_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	028	0		29	10	S5670_028_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	71.00	213.00								71.00			213.00								71.00
S5670	028	0		29	10	S5670_028_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	030	0		29	10	S5670_030_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	030	0		29	10	S5670_030_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	030	0		29	10	S5670_030_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	030	0		29	10	S5670_030_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	030	0		29	10	S5670_030_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	030	0		29	10	S5670_030_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	030	0		29	10	S5670_030_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	030	0		29	10	S5670_030_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	033	0		29	10	S5670_033_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	033	0		29	10	S5670_033_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	033	0		29	10	S5670_033_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	033	0		29	10	S5670_033_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	034	0		29	10	S5670_034_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	034	0		29	10	S5670_034_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	62.00								31.00			62.00								31.00
S5670	034	0		29	10	S5670_034_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	034	0		29	10	S5670_034_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
S5670	036	0		29	10	S5670_036_0	7	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	036	0		29	10	S5670_036_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
S5670	036	0		29	10	S5670_036_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5670	036	0		29	10	S5670_036_0	7	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	036	0		29	10	S5670_036_0	7	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	036	0		29	10	S5670_036_0	7	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	036	0		29	10	S5670_036_0	7	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	036	0		29	10	S5670_036_0	7	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	039	0		29	10	S5670_039_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	039	0		29	10	S5670_039_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	039	0		29	10	S5670_039_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	039	0		29	10	S5670_039_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	040	0		29	10	S5670_040_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	040	0		29	10	S5670_040_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	62.00								31.00			62.00								31.00
S5670	040	0		29	10	S5670_040_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	040	0		29	10	S5670_040_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5670	042	0		29	10	S5670_042_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	042	0		29	10	S5670_042_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	042	0		29	10	S5670_042_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	042	0		29	10	S5670_042_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	042	0		29	10	S5670_042_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	042	0		29	10	S5670_042_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	042	0		29	10	S5670_042_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	042	0		29	10	S5670_042_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	045	0		29	10	S5670_045_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	045	0		29	10	S5670_045_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	045	0		29	10	S5670_045_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	045	0		29	10	S5670_045_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	046	0		29	10	S5670_046_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	046	0		29	10	S5670_046_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	046	0		29	10	S5670_046_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	77.00	231.00								77.00			231.00								77.00
S5670	046	0		29	10	S5670_046_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	048	0		29	10	S5670_048_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	048	0		29	10	S5670_048_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	048	0		29	10	S5670_048_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	048	0		29	10	S5670_048_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	048	0		29	10	S5670_048_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
S5670	048	0		29	10	S5670_048_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	048	0		29	10	S5670_048_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	048	0		29	10	S5670_048_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	051	0		29	10	S5670_051_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	051	0		29	10	S5670_051_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	051	0		29	10	S5670_051_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	051	0		29	10	S5670_051_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	052	0		29	10	S5670_052_0	7	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	052	0		29	10	S5670_052_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00			56.00								28.00
S5670	052	0		29	10	S5670_052_0	7	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00			201.00								67.00
S5670	052	0		29	10	S5670_052_0	7	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	054	0		29	10	S5670_054_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
S5670	054	0		29	10	S5670_054_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	64.00								32.00			64.00								32.00
S5670	054	0		29	10	S5670_054_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	054	0		29	10	S5670_054_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	054	0		29	10	S5670_054_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	054	0		29	10	S5670_054_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	054	0		29	10	S5670_054_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	054	0		29	10	S5670_054_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	057	0		29	10	S5670_057_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	057	0		29	10	S5670_057_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	057	0		29	10	S5670_057_0	7	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	057	0		29	10	S5670_057_0	7	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	058	0		29	10	S5670_058_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5670	058	0		29	10	S5670_058_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	058	0		29	10	S5670_058_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	058	0		29	10	S5670_058_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	060	0		29	10	S5670_060_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	060	0		29	10	S5670_060_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	060	0		29	10	S5670_060_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	060	0		29	10	S5670_060_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	060	0		29	10	S5670_060_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	060	0		29	10	S5670_060_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	060	0		29	10	S5670_060_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	060	0		29	10	S5670_060_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	063	0		29	10	S5670_063_0	6	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	063	0		29	10	S5670_063_0	6	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	57.00	171.00								57.00			171.00								57.00
S5670	063	0		29	10	S5670_063_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	063	0		29	10	S5670_063_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	064	0		29	10	S5670_064_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	064	0		29	10	S5670_064_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	064	0		29	10	S5670_064_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5670	064	0		29	10	S5670_064_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	066	0		29	10	S5670_066_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	066	0		29	10	S5670_066_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	066	0		29	10	S5670_066_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	066	0		29	10	S5670_066_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	066	0		29	10	S5670_066_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	066	0		29	10	S5670_066_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	066	0		29	10	S5670_066_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	066	0		29	10	S5670_066_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	069	0		29	10	S5670_069_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	069	0		29	10	S5670_069_0	6	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	069	0		29	10	S5670_069_0	6	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	50.00	150.00								50.00			150.00								50.00
S5670	069	0		29	10	S5670_069_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	23.00	46.00								23.00			46.00								23.00
S5670	070	0		29	10	S5670_070_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	070	0		29	10	S5670_070_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00
S5670	070	0		29	10	S5670_070_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	070	0		29	10	S5670_070_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	072	0		29	10	S5670_072_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	072	0		29	10	S5670_072_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	072	0		29	10	S5670_072_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	072	0		29	10	S5670_072_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	072	0		29	10	S5670_072_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	072	0		29	10	S5670_072_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	072	0		29	10	S5670_072_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	072	0		29	10	S5670_072_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	075	0		29	10	S5670_075_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	075	0		29	10	S5670_075_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	075	0		29	10	S5670_075_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	075	0		29	10	S5670_075_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	076	0		29	10	S5670_076_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	076	0		29	10	S5670_076_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	076	0		29	10	S5670_076_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	076	0		29	10	S5670_076_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	078	0		29	10	S5670_078_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	078	0		29	10	S5670_078_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	078	0		29	10	S5670_078_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	078	0		29	10	S5670_078_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	078	0		29	10	S5670_078_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	078	0		29	10	S5670_078_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	078	0		29	10	S5670_078_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	078	0		29	10	S5670_078_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	081	0		29	10	S5670_081_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	081	0		29	10	S5670_081_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	081	0		29	10	S5670_081_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	081	0		29	10	S5670_081_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	082	0		29	10	S5670_082_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	082	0		29	10	S5670_082_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	082	0		29	10	S5670_082_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00			186.00								62.00
S5670	082	0		29	10	S5670_082_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	084	0		29	10	S5670_084_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
S5670	084	0		29	10	S5670_084_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	084	0		29	10	S5670_084_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	084	0		29	10	S5670_084_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	084	0		29	10	S5670_084_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	084	0		29	10	S5670_084_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	084	0		29	10	S5670_084_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	084	0		29	10	S5670_084_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	087	0		29	10	S5670_087_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	087	0		29	10	S5670_087_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	087	0		29	10	S5670_087_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	087	0		29	10	S5670_087_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	088	0		29	10	S5670_088_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	088	0		29	10	S5670_088_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5670	088	0		29	10	S5670_088_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	088	0		29	10	S5670_088_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	090	0		29	10	S5670_090_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	090	0		29	10	S5670_090_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	090	0		29	10	S5670_090_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	090	0		29	10	S5670_090_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	090	0		29	10	S5670_090_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	090	0		29	10	S5670_090_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	090	0		29	10	S5670_090_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	090	0		29	10	S5670_090_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	093	0		29	10	S5670_093_0	7	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	093	0		29	10	S5670_093_0	7	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	093	0		29	10	S5670_093_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	093	0		29	10	S5670_093_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	094	0		29	10	S5670_094_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	094	0		29	10	S5670_094_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	094	0		29	10	S5670_094_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5670	094	0		29	10	S5670_094_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	096	0		29	10	S5670_096_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	096	0		29	10	S5670_096_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	096	0		29	10	S5670_096_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	096	0		29	10	S5670_096_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	096	0		29	10	S5670_096_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	096	0		29	10	S5670_096_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	096	0		29	10	S5670_096_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	096	0		29	10	S5670_096_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	099	0		29	10	S5670_099_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	099	0		29	10	S5670_099_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	099	0		29	10	S5670_099_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	099	0		29	10	S5670_099_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	100	0		29	10	S5670_100_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	100	0		29	10	S5670_100_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5670	100	0		29	10	S5670_100_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	100	0		29	10	S5670_100_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	102	0		29	10	S5670_102_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	102	0		29	10	S5670_102_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	102	0		29	10	S5670_102_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	102	0		29	10	S5670_102_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	102	0		29	10	S5670_102_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	102	0		29	10	S5670_102_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	102	0		29	10	S5670_102_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	102	0		29	10	S5670_102_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	105	0		29	10	S5670_105_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	105	0		29	10	S5670_105_0	6	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	62.00	186.00								62.00			186.00								62.00
S5670	105	0		29	10	S5670_105_0	6	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	105	0		29	10	S5670_105_0	6	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	106	0		29	10	S5670_106_0	7	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	106	0		29	10	S5670_106_0	7	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	106	0		29	10	S5670_106_0	7	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5670	106	0		29	10	S5670_106_0	7	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	108	0		29	10	S5670_108_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	108	0		29	10	S5670_108_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	108	0		29	10	S5670_108_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	108	0		29	10	S5670_108_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	108	0		29	10	S5670_108_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	108	0		29	10	S5670_108_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	108	0		29	10	S5670_108_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	108	0		29	10	S5670_108_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	111	0		29	10	S5670_111_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	111	0		29	10	S5670_111_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	111	0		29	10	S5670_111_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	111	0		29	10	S5670_111_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	112	0		29	10	S5670_112_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	112	0		29	10	S5670_112_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	112	0		29	10	S5670_112_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
S5670	112	0		29	10	S5670_112_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	114	0		29	10	S5670_114_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	114	0		29	10	S5670_114_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	114	0		29	10	S5670_114_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	114	0		29	10	S5670_114_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	114	0		29	10	S5670_114_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	114	0		29	10	S5670_114_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	114	0		29	10	S5670_114_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	114	0		29	10	S5670_114_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	117	0		29	10	S5670_117_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	117	0		29	10	S5670_117_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	117	0		29	10	S5670_117_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	117	0		29	10	S5670_117_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	118	0		29	10	S5670_118_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	5.00	10.00								5.00			10.00								5.00
S5670	118	0		29	10	S5670_118_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	118	0		29	10	S5670_118_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
S5670	118	0		29	10	S5670_118_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	120	0		29	10	S5670_120_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	120	0		29	10	S5670_120_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	120	0		29	10	S5670_120_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	120	0		29	10	S5670_120_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	120	0		29	10	S5670_120_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	120	0		29	10	S5670_120_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	120	0		29	10	S5670_120_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	120	0		29	10	S5670_120_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	123	0		29	10	S5670_123_0	7	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	123	0		29	10	S5670_123_0	7	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	123	0		29	10	S5670_123_0	7	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	123	0		29	10	S5670_123_0	7	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	124	0		29	10	S5670_124_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	124	0		29	10	S5670_124_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5670	124	0		29	10	S5670_124_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	124	0		29	10	S5670_124_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00
S5670	126	0		29	10	S5670_126_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S5670	126	0		29	10	S5670_126_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	66.00								33.00			66.00								33.00
S5670	126	0		29	10	S5670_126_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	126	0		29	10	S5670_126_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	126	0		29	10	S5670_126_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	126	0		29	10	S5670_126_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	126	0		29	10	S5670_126_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	126	0		29	10	S5670_126_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	129	0		29	10	S5670_129_0	5	1	4	1	Preferred Genric	001000	1	2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	8.00	16.00								8.00			16.00								8.00
S5670	129	0		29	10	S5670_129_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S5670	129	0		29	10	S5670_129_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	129	0		29	10	S5670_129_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	130	0		29	10	S5670_130_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	130	0		29	10	S5670_130_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	54.00								27.00			54.00								27.00
S5670	130	0		29	10	S5670_130_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	130	0		29	10	S5670_130_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
S5670	132	0		29	10	S5670_132_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	132	0		29	10	S5670_132_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	132	0		29	10	S5670_132_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	132	0		29	10	S5670_132_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	132	0		29	10	S5670_132_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	132	0		29	10	S5670_132_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	132	0		29	10	S5670_132_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	132	0		29	10	S5670_132_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	135	0		29	10	S5670_135_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	135	0		29	10	S5670_135_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	65.00	195.00								65.00			195.00								65.00
S5670	135	0		29	10	S5670_135_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	54.00								27.00			54.00								27.00
S5670	135	0		29	10	S5670_135_0	5	1	4	1	Preferred Genric	001000	1	2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	9.00	18.00								9.00			18.00								9.00
S5670	136	0		29	10	S5670_136_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	136	0		29	10	S5670_136_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	63.00	189.00								63.00			189.00								63.00
S5670	136	0		29	10	S5670_136_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	136	0		29	10	S5670_136_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	7.00	14.00								7.00			14.00								7.00
S5670	138	0		29	10	S5670_138_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	138	0		29	10	S5670_138_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	138	0		29	10	S5670_138_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	138	0		29	10	S5670_138_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	138	0		29	10	S5670_138_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	138	0		29	10	S5670_138_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	138	0		29	10	S5670_138_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	138	0		29	10	S5670_138_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	141	0		29	10	S5670_141_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5670	141	0		29	10	S5670_141_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5670	141	0		29	10	S5670_141_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	141	0		29	10	S5670_141_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5670	142	0		29	10	S5670_142_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5670	142	0		29	10	S5670_142_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	71.00	213.00								71.00			213.00								71.00
S5670	142	0		29	10	S5670_142_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	142	0		29	10	S5670_142_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	144	0		29	10	S5670_144_0	5	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	144	0		29	10	S5670_144_0	5	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	144	0		29	10	S5670_144_0	5	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	144	0		29	10	S5670_144_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	144	0		29	10	S5670_144_0	5	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	144	0		29	10	S5670_144_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	144	0		29	10	S5670_144_0	5	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	144	0		29	10	S5670_144_0	5	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	147	0		29	10	S5670_147_0	5	4	4	1	Specialty- Generic and Brand	010010	1	1				Specialty- Generic and Brand	110000000010000000000	30									30											31	Specialty- Generic and Brand	2	1	Specialty- Generic and Brand	33									33											33	Specialty- Generic and Brand																					
S5670	147	0		29	10	S5670_147_0	5	3	4	1	Non-Preferred Genric/Non Preferred Brand	100100	1	2				Non-Preferred Genric/Non Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Genric/Non Preferred Brand	2	2	Non-Preferred Genric/Non Preferred Brand																						Non-Preferred Genric/Non Preferred Brand	65.00	195.00								65.00			195.00								65.00
S5670	147	0		29	10	S5670_147_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5670	147	0		29	10	S5670_147_0	5	1	4	1	Preferred Genric	001000	1	2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	9.00	18.00								9.00			18.00								9.00
S5670	148	0		29	10	S5670_148_0	6	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5670	148	0		29	10	S5670_148_0	6	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5670	148	0		29	10	S5670_148_0	6	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	148	0		29	10	S5670_148_0	6	1	3	1	Preferred Genric	001000		2				Preferred Genric	111000000010010000000	30	90								30										90	31	Preferred Genric	2	2	Preferred Genric																						Preferred Genric	6.00	12.00								6.00			12.00								6.00
S5670	150	0		29	10	S5670_150_0	6	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5670	150	0		29	10	S5670_150_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5670	150	0		29	10	S5670_150_0	6	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5670	150	0		29	10	S5670_150_0	6	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5670	150	0		29	10	S5670_150_0	6	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5670	150	0		29	10	S5670_150_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5670	150	0		29	10	S5670_150_0	6	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5670	150	0		29	10	S5670_150_0	6	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	002	0		29	10	S5674_002_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	002	0		29	10	S5674_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00
S5674	002	0		29	10	S5674_002_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
S5674	002	0		29	10	S5674_002_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	003	0		29	10	S5674_003_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
S5674	003	0		29	10	S5674_003_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00			56.00								28.00
S5674	003	0		29	10	S5674_003_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00
S5674	003	0		29	10	S5674_003_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	005	0		29	10	S5674_005_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5674	005	0		29	10	S5674_005_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	005	0		29	10	S5674_005_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	005	0		29	10	S5674_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	005	0		29	10	S5674_005_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	005	0		29	10	S5674_005_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	005	0		29	10	S5674_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	005	0		29	10	S5674_005_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	008	0		29	10	S5674_008_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	008	0		29	10	S5674_008_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	008	0		29	10	S5674_008_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S5674	008	0		29	10	S5674_008_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00
S5674	009	0		29	10	S5674_009_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	68.00	204.00								68.00			204.00								68.00
S5674	009	0		29	10	S5674_009_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	54.00								27.00			54.00								27.00
S5674	009	0		29	10	S5674_009_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S5674	009	0		29	10	S5674_009_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	011	0		29	10	S5674_011_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	011	0		29	10	S5674_011_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	011	0		29	10	S5674_011_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
S5674	011	0		29	10	S5674_011_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	011	0		29	10	S5674_011_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	011	0		29	10	S5674_011_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	011	0		29	10	S5674_011_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	011	0		29	10	S5674_011_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	014	0		29	10	S5674_014_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	014	0		29	10	S5674_014_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	014	0		29	10	S5674_014_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	014	0		29	10	S5674_014_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	015	0		29	10	S5674_015_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
S5674	015	0		29	10	S5674_015_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5674	015	0		29	10	S5674_015_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	69.00	207.00								69.00			207.00								69.00
S5674	015	0		29	10	S5674_015_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	017	0		29	10	S5674_017_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	017	0		29	10	S5674_017_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	017	0		29	10	S5674_017_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	71.00	213.00								71.00			213.00								71.00
S5674	017	0		29	10	S5674_017_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	017	0		29	10	S5674_017_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	017	0		29	10	S5674_017_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	017	0		29	10	S5674_017_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	017	0		29	10	S5674_017_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	020	0		29	10	S5674_020_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	020	0		29	10	S5674_020_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	020	0		29	10	S5674_020_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	56.00	168.00								56.00			168.00								56.00
S5674	020	0		29	10	S5674_020_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	021	0		29	10	S5674_021_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
S5674	021	0		29	10	S5674_021_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	021	0		29	10	S5674_021_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S5674	021	0		29	10	S5674_021_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	023	0		29	10	S5674_023_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	023	0		29	10	S5674_023_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	023	0		29	10	S5674_023_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	023	0		29	10	S5674_023_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	023	0		29	10	S5674_023_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	023	0		29	10	S5674_023_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
S5674	023	0		29	10	S5674_023_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
S5674	023	0		29	10	S5674_023_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	026	0		29	10	S5674_026_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	026	0		29	10	S5674_026_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	026	0		29	10	S5674_026_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	026	0		29	10	S5674_026_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	027	0		29	10	S5674_027_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	027	0		29	10	S5674_027_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S5674	027	0		29	10	S5674_027_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5674	027	0		29	10	S5674_027_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	029	0		29	10	S5674_029_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5674	029	0		29	10	S5674_029_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	029	0		29	10	S5674_029_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	029	0		29	10	S5674_029_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	029	0		29	10	S5674_029_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	029	0		29	10	S5674_029_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	029	0		29	10	S5674_029_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	029	0		29	10	S5674_029_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	032	0		29	10	S5674_032_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	032	0		29	10	S5674_032_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	032	0		29	10	S5674_032_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	032	0		29	10	S5674_032_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	033	0		29	10	S5674_033_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
S5674	033	0		29	10	S5674_033_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00			56.00								28.00
S5674	033	0		29	10	S5674_033_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00
S5674	033	0		29	10	S5674_033_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	035	0		29	10	S5674_035_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5674	035	0		29	10	S5674_035_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
S5674	035	0		29	10	S5674_035_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	035	0		29	10	S5674_035_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	035	0		29	10	S5674_035_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	035	0		29	10	S5674_035_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	035	0		29	10	S5674_035_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	035	0		29	10	S5674_035_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	038	0		29	10	S5674_038_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	038	0		29	10	S5674_038_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	038	0		29	10	S5674_038_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00
S5674	038	0		29	10	S5674_038_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	039	0		29	10	S5674_039_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00
S5674	039	0		29	10	S5674_039_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	039	0		29	10	S5674_039_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	039	0		29	10	S5674_039_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	041	0		29	10	S5674_041_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5674	041	0		29	10	S5674_041_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	041	0		29	10	S5674_041_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	041	0		29	10	S5674_041_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	041	0		29	10	S5674_041_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	041	0		29	10	S5674_041_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	041	0		29	10	S5674_041_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	041	0		29	10	S5674_041_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	044	0		29	10	S5674_044_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
S5674	044	0		29	10	S5674_044_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00
S5674	044	0		29	10	S5674_044_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	044	0		29	10	S5674_044_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	045	0		29	10	S5674_045_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	71.00	213.00								71.00			213.00								71.00
S5674	045	0		29	10	S5674_045_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	54.00								27.00			54.00								27.00
S5674	045	0		29	10	S5674_045_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
S5674	045	0		29	10	S5674_045_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	047	0		29	10	S5674_047_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	047	0		29	10	S5674_047_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	047	0		29	10	S5674_047_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	047	0		29	10	S5674_047_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	047	0		29	10	S5674_047_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5674	047	0		29	10	S5674_047_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	047	0		29	10	S5674_047_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	047	0		29	10	S5674_047_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	050	0		29	10	S5674_050_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	050	0		29	10	S5674_050_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	050	0		29	10	S5674_050_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	050	0		29	10	S5674_050_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	051	0		29	10	S5674_051_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5674	051	0		29	10	S5674_051_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	12.00								6.00			12.00								6.00
S5674	051	0		29	10	S5674_051_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	62.00								31.00			62.00								31.00
S5674	051	0		29	10	S5674_051_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	053	0		29	10	S5674_053_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	053	0		29	10	S5674_053_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	053	0		29	10	S5674_053_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5674	053	0		29	10	S5674_053_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	053	0		29	10	S5674_053_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	053	0		29	10	S5674_053_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	053	0		29	10	S5674_053_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	053	0		29	10	S5674_053_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	056	0		29	10	S5674_056_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00
S5674	056	0		29	10	S5674_056_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	056	0		29	10	S5674_056_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	056	0		29	10	S5674_056_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S5674	057	0		29	10	S5674_057_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	52.00								26.00			52.00								26.00
S5674	057	0		29	10	S5674_057_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00			201.00								67.00
S5674	057	0		29	10	S5674_057_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	057	0		29	10	S5674_057_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
S5674	059	0		29	10	S5674_059_0	3	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	059	0		29	10	S5674_059_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00
S5674	059	0		29	10	S5674_059_0	3	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	75.00	225.00								75.00			225.00								75.00
S5674	059	0		29	10	S5674_059_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	059	0		29	10	S5674_059_0	3	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	059	0		29	10	S5674_059_0	3	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	059	0		29	10	S5674_059_0	3	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	059	0		29	10	S5674_059_0	3	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	062	0		29	10	S5674_062_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	24.00	48.00								24.00			48.00								24.00
S5674	062	0		29	10	S5674_062_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00
S5674	062	0		29	10	S5674_062_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	062	0		29	10	S5674_062_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	16.00								8.00			16.00								8.00
S5674	063	0		29	10	S5674_063_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5674	063	0		29	10	S5674_063_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	063	0		29	10	S5674_063_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00			56.00								28.00
S5674	063	0		29	10	S5674_063_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	14.00								7.00			14.00								7.00
S5674	065	0		29	10	S5674_065_0	2	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	065	0		29	10	S5674_065_0	2	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	065	0		29	10	S5674_065_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	065	0		29	10	S5674_065_0	2	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5674	065	0		29	10	S5674_065_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
S5674	065	0		29	10	S5674_065_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00
S5674	065	0		29	10	S5674_065_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	065	0		29	10	S5674_065_0	2	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	068	0		29	10	S5674_068_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00
S5674	068	0		29	10	S5674_068_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S5674	068	0		29	10	S5674_068_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	068	0		29	10	S5674_068_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	53.00	159.00								53.00			159.00								53.00
S5674	069	0		29	10	S5674_069_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	66.00	198.00								66.00			198.00								66.00
S5674	069	0		29	10	S5674_069_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00
S5674	069	0		29	10	S5674_069_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00			10.00								5.00
S5674	069	0		29	10	S5674_069_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	071	0		29	10	S5674_071_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5674	071	0		29	10	S5674_071_0	2	1	4	3	Preferred Generic	001000	3	2	1		1	Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	15.00	30.00								15.00			30.00								15.00
S5674	071	0		29	10	S5674_071_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5674	071	0		29	10	S5674_071_0	2	4	4	3	Specialty-Generic and Brand	010010	1	1	2			Specialty-Generic and Brand																							Specialty-Generic and Brand			Specialty-Generic and Brand																						Specialty-Generic and Brand																					
S5674	071	0		29	10	S5674_071_0	2	3	4	3	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	2			Non-Preferred Generic/Non-Preferred Brand																							Non-Preferred Generic/Non-Preferred Brand			Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																					
S5674	071	0		29	10	S5674_071_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5674	071	0		29	10	S5674_071_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	58.00								29.00			58.00								29.00
S5674	071	0		29	10	S5674_071_0	2	1	4	1	Preferred Generic	001000	3	2				Preferred Generic	111000000010010000000	30	90								30										90	31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	8.00								4.00			8.00								4.00
S5678	001	0		29	10	S5678_001_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	001	0		29	10	S5678_001_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	001	0		29	10	S5678_001_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	001	0		29	10	S5678_001_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	001	0		29	10	S5678_001_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00	80.00							40.00						80.00	80.00	40.00	120.00	80.00	40.00
S5678	002	0		29	10	S5678_002_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	002	0		29	10	S5678_002_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00						74.00	74.00	37.00	111.00	74.00	37.00
S5678	002	0		29	10	S5678_002_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	002	0		29	10	S5678_002_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	002	0		29	10	S5678_002_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	003	0		29	10	S5678_003_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	003	0		29	10	S5678_003_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	003	0		29	10	S5678_003_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	003	0		29	10	S5678_003_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	003	0		29	10	S5678_003_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	004	0		29	10	S5678_004_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	004	0		29	10	S5678_004_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	004	0		29	10	S5678_004_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	004	0		29	10	S5678_004_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	004	0		29	10	S5678_004_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	005	0		29	10	S5678_005_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	005	0		29	10	S5678_005_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	005	0		29	10	S5678_005_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	40.00	120.00	80.00							40.00						80.00	80.00	40.00	120.00	80.00	40.00
S5678	005	0		29	10	S5678_005_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	005	0		29	10	S5678_005_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	006	0		29	10	S5678_006_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	006	0		29	10	S5678_006_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	006	0		29	10	S5678_006_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	006	0		29	10	S5678_006_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	006	0		29	10	S5678_006_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	007	0		29	10	S5678_007_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	007	0		29	10	S5678_007_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	007	0		29	10	S5678_007_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	007	0		29	10	S5678_007_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	007	0		29	10	S5678_007_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	008	0		29	10	S5678_008_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	008	0		29	10	S5678_008_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	008	0		29	10	S5678_008_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	008	0		29	10	S5678_008_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	008	0		29	10	S5678_008_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	009	0		29	10	S5678_009_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	009	0		29	10	S5678_009_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	009	0		29	10	S5678_009_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	009	0		29	10	S5678_009_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	009	0		29	10	S5678_009_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	010	0		29	10	S5678_010_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	010	0		29	10	S5678_010_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	010	0		29	10	S5678_010_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	010	0		29	10	S5678_010_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	010	0		29	10	S5678_010_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	011	0		29	10	S5678_011_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	011	0		29	10	S5678_011_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	011	0		29	10	S5678_011_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	011	0		29	10	S5678_011_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	011	0		29	10	S5678_011_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	012	0		29	10	S5678_012_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	012	0		29	10	S5678_012_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	012	0		29	10	S5678_012_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	012	0		29	10	S5678_012_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	012	0		29	10	S5678_012_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	013	0		29	10	S5678_013_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	013	0		29	10	S5678_013_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	013	0		29	10	S5678_013_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	013	0		29	10	S5678_013_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	013	0		29	10	S5678_013_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	014	0		29	10	S5678_014_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	014	0		29	10	S5678_014_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	014	0		29	10	S5678_014_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	014	0		29	10	S5678_014_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	014	0		29	10	S5678_014_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	015	0		29	10	S5678_015_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	015	0		29	10	S5678_015_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	015	0		29	10	S5678_015_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	015	0		29	10	S5678_015_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	015	0		29	10	S5678_015_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	016	0		29	10	S5678_016_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	016	0		29	10	S5678_016_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	45.00	135.00	90.00							45.00						90.00	90.00	45.00	135.00	90.00	45.00
S5678	016	0		29	10	S5678_016_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	016	0		29	10	S5678_016_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	016	0		29	10	S5678_016_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	017	0		29	10	S5678_017_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	017	0		29	10	S5678_017_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	017	0		29	10	S5678_017_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	017	0		29	10	S5678_017_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	017	0		29	10	S5678_017_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	018	0		29	10	S5678_018_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	018	0		29	10	S5678_018_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	018	0		29	10	S5678_018_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	018	0		29	10	S5678_018_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	018	0		29	10	S5678_018_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	019	0		29	10	S5678_019_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	019	0		29	10	S5678_019_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	019	0		29	10	S5678_019_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	019	0		29	10	S5678_019_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	019	0		29	10	S5678_019_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	020	0		29	10	S5678_020_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	020	0		29	10	S5678_020_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	020	0		29	10	S5678_020_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	020	0		29	10	S5678_020_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
S5678	020	0		29	10	S5678_020_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	021	0		29	10	S5678_021_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	021	0		29	10	S5678_021_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	021	0		29	10	S5678_021_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	021	0		29	10	S5678_021_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	021	0		29	10	S5678_021_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	022	0		29	10	S5678_022_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	022	0		29	10	S5678_022_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	022	0		29	10	S5678_022_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	022	0		29	10	S5678_022_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	022	0		29	10	S5678_022_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	023	0		29	10	S5678_023_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	023	0		29	10	S5678_023_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	023	0		29	10	S5678_023_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	023	0		29	10	S5678_023_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	023	0		29	10	S5678_023_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	024	0		29	10	S5678_024_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	024	0		29	10	S5678_024_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	024	0		29	10	S5678_024_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	024	0		29	10	S5678_024_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	024	0		29	10	S5678_024_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	025	0		29	10	S5678_025_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	025	0		29	10	S5678_025_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	025	0		29	10	S5678_025_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	025	0		29	10	S5678_025_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	025	0		29	10	S5678_025_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	026	0		29	10	S5678_026_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	41.00	123.00	82.00							41.00						82.00	82.00	41.00	123.00	82.00	41.00
S5678	026	0		29	10	S5678_026_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	026	0		29	10	S5678_026_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	026	0		29	10	S5678_026_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	026	0		29	10	S5678_026_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	027	0		29	10	S5678_027_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	027	0		29	10	S5678_027_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	027	0		29	10	S5678_027_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	027	0		29	10	S5678_027_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	027	0		29	10	S5678_027_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	028	0		29	10	S5678_028_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	028	0		29	10	S5678_028_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	028	0		29	10	S5678_028_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	028	0		29	10	S5678_028_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	028	0		29	10	S5678_028_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	029	0		29	10	S5678_029_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	029	0		29	10	S5678_029_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	029	0		29	10	S5678_029_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	029	0		29	10	S5678_029_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	029	0		29	10	S5678_029_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	030	0		29	10	S5678_030_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	030	0		29	10	S5678_030_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	030	0		29	10	S5678_030_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	030	0		29	10	S5678_030_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	030	0		29	10	S5678_030_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	031	0		29	10	S5678_031_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	031	0		29	10	S5678_031_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	031	0		29	10	S5678_031_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	031	0		29	10	S5678_031_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	031	0		29	10	S5678_031_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	032	0		29	10	S5678_032_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	032	0		29	10	S5678_032_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	032	0		29	10	S5678_032_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	032	0		29	10	S5678_032_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	032	0		29	10	S5678_032_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	033	0		29	10	S5678_033_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	033	0		29	10	S5678_033_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	033	0		29	10	S5678_033_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	033	0		29	10	S5678_033_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	033	0		29	10	S5678_033_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	034	0		29	10	S5678_034_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	034	0		29	10	S5678_034_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
S5678	034	0		29	10	S5678_034_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	034	0		29	10	S5678_034_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	034	0		29	10	S5678_034_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	035	0		29	10	S5678_035_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	035	0		29	10	S5678_035_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	035	0		29	10	S5678_035_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	035	0		29	10	S5678_035_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	035	0		29	10	S5678_035_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	036	0		29	10	S5678_036_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	036	0		29	10	S5678_036_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	036	0		29	10	S5678_036_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
S5678	036	0		29	10	S5678_036_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	036	0		29	10	S5678_036_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	037	0		29	10	S5678_037_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	037	0		29	10	S5678_037_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	037	0		29	10	S5678_037_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	037	0		29	10	S5678_037_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	037	0		29	10	S5678_037_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	038	0		29	10	S5678_038_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	038	0		29	10	S5678_038_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	038	0		29	10	S5678_038_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	038	0		29	10	S5678_038_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	038	0		29	10	S5678_038_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	039	0		29	10	S5678_039_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	039	0		29	10	S5678_039_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	039	0		29	10	S5678_039_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	039	0		29	10	S5678_039_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	039	0		29	10	S5678_039_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	040	0		29	10	S5678_040_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	040	0		29	10	S5678_040_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
S5678	040	0		29	10	S5678_040_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	040	0		29	10	S5678_040_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	040	0		29	10	S5678_040_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	041	0		29	10	S5678_041_0	3	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	041	0		29	10	S5678_041_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	041	0		29	10	S5678_041_0	3	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	041	0		29	10	S5678_041_0	3	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	041	0		29	10	S5678_041_0	3	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	042	0		29	10	S5678_042_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	042	0		29	10	S5678_042_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	042	0		29	10	S5678_042_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	042	0		29	10	S5678_042_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	042	0		29	10	S5678_042_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	043	0		29	10	S5678_043_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	043	0		29	10	S5678_043_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	043	0		29	10	S5678_043_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	043	0		29	10	S5678_043_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	043	0		29	10	S5678_043_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	044	0		29	10	S5678_044_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	044	0		29	10	S5678_044_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	044	0		29	10	S5678_044_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	044	0		29	10	S5678_044_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	044	0		29	10	S5678_044_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	045	0		29	10	S5678_045_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	045	0		29	10	S5678_045_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	045	0		29	10	S5678_045_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	045	0		29	10	S5678_045_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	045	0		29	10	S5678_045_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	046	0		29	10	S5678_046_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	046	0		29	10	S5678_046_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	046	0		29	10	S5678_046_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	046	0		29	10	S5678_046_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	42.00	126.00	84.00							42.00						84.00	84.00	42.00	126.00	84.00	42.00
S5678	046	0		29	10	S5678_046_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	047	0		29	10	S5678_047_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	047	0		29	10	S5678_047_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	047	0		29	10	S5678_047_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	047	0		29	10	S5678_047_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	047	0		29	10	S5678_047_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	048	0		29	10	S5678_048_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	048	0		29	10	S5678_048_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	048	0		29	10	S5678_048_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	048	0		29	10	S5678_048_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	41.00	123.00	82.00							41.00						82.00	82.00	41.00	123.00	82.00	41.00
S5678	048	0		29	10	S5678_048_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	049	0		29	10	S5678_049_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	049	0		29	10	S5678_049_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	049	0		29	10	S5678_049_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	049	0		29	10	S5678_049_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	049	0		29	10	S5678_049_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	050	0		29	10	S5678_050_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	050	0		29	10	S5678_050_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	050	0		29	10	S5678_050_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	050	0		29	10	S5678_050_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	050	0		29	10	S5678_050_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	051	0		29	10	S5678_051_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	051	0		29	10	S5678_051_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	051	0		29	10	S5678_051_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	051	0		29	10	S5678_051_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	051	0		29	10	S5678_051_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	052	0		29	10	S5678_052_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	052	0		29	10	S5678_052_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	052	0		29	10	S5678_052_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	052	0		29	10	S5678_052_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	45.00	135.00	90.00							45.00						90.00	90.00	45.00	135.00	90.00	45.00
S5678	052	0		29	10	S5678_052_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	053	0		29	10	S5678_053_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	053	0		29	10	S5678_053_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	053	0		29	10	S5678_053_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	053	0		29	10	S5678_053_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	053	0		29	10	S5678_053_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	054	0		29	10	S5678_054_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	054	0		29	10	S5678_054_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	45.00	135.00	90.00							45.00						90.00	90.00	45.00	135.00	90.00	45.00
S5678	054	0		29	10	S5678_054_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	054	0		29	10	S5678_054_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	054	0		29	10	S5678_054_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	055	0		29	10	S5678_055_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	055	0		29	10	S5678_055_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	055	0		29	10	S5678_055_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	055	0		29	10	S5678_055_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	055	0		29	10	S5678_055_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	056	0		29	10	S5678_056_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	056	0		29	10	S5678_056_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	056	0		29	10	S5678_056_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	056	0		29	10	S5678_056_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	056	0		29	10	S5678_056_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	057	0		29	10	S5678_057_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	057	0		29	10	S5678_057_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	057	0		29	10	S5678_057_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	057	0		29	10	S5678_057_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	057	0		29	10	S5678_057_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	058	0		29	10	S5678_058_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	058	0		29	10	S5678_058_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	058	0		29	10	S5678_058_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	058	0		29	10	S5678_058_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	058	0		29	10	S5678_058_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	059	0		29	10	S5678_059_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	059	0		29	10	S5678_059_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	059	0		29	10	S5678_059_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	059	0		29	10	S5678_059_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	059	0		29	10	S5678_059_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	060	0		29	10	S5678_060_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	060	0		29	10	S5678_060_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	060	0		29	10	S5678_060_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	060	0		29	10	S5678_060_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	060	0		29	10	S5678_060_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	061	0		29	10	S5678_061_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	061	0		29	10	S5678_061_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	061	0		29	10	S5678_061_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	061	0		29	10	S5678_061_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	061	0		29	10	S5678_061_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	062	0		29	10	S5678_062_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	062	0		29	10	S5678_062_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	062	0		29	10	S5678_062_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	062	0		29	10	S5678_062_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	062	0		29	10	S5678_062_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	063	0		29	10	S5678_063_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	063	0		29	10	S5678_063_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	063	0		29	10	S5678_063_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	063	0		29	10	S5678_063_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	063	0		29	10	S5678_063_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	064	0		29	10	S5678_064_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	064	0		29	10	S5678_064_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	064	0		29	10	S5678_064_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	064	0		29	10	S5678_064_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	064	0		29	10	S5678_064_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	065	0		29	10	S5678_065_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	065	0		29	10	S5678_065_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	065	0		29	10	S5678_065_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00						60.00	60.00	30.00	90.00	60.00	30.00
S5678	065	0		29	10	S5678_065_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00						10.00	10.00	5.00	15.00	10.00	5.00
S5678	065	0		29	10	S5678_065_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	066	0		29	10	S5678_066_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	066	0		29	10	S5678_066_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	066	0		29	10	S5678_066_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	43.00	129.00	86.00							43.00						86.00	86.00	43.00	129.00	86.00	43.00
S5678	066	0		29	10	S5678_066_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	066	0		29	10	S5678_066_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5678	067	0		29	10	S5678_067_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00						0.00	0.00	0.00	0.00	0.00	0.00
S5678	067	0		29	10	S5678_067_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00						78.00	78.00	39.00	117.00	78.00	39.00
S5678	067	0		29	10	S5678_067_0	2	3	4	1	Non-Preferred Brand	100100	1	2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00	150.00							75.00						188.00	150.00	75.00	225.00	150.00	75.00
S5678	067	0		29	10	S5678_067_0	2	4	4	1	Injectable	010010	1	2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	33									33					33			33			33	Injectable																					
S5678	067	0		29	10	S5678_067_0	2	5	4	1	Specialty	010010	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5678	068	0		29	10	S5678_068_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	2.00	6.00	4.00							2.00						4.00	4.00	2.00	6.00	4.00	2.00
S5678	068	0		29	10	S5678_068_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	44.00	132.00	88.00							44.00						88.00	88.00	44.00	132.00	88.00	44.00
S5678	068	0		29	10	S5678_068_0	2	4	2	1	Injectable	010010		2				Injectable	110000000010000100100	30									30				30			30				34	Injectable	1	1	Injectable	25									25					25			25			25	Injectable																					
S5678	068	0		29	10	S5678_068_0	2	3	2	1	Non-Preferred Brand	100100		2				Non-Preferred Brand	111100000010000011111	30	90	60							30					90	60	30	90	60		34	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00						225.00	180.00	90.00	270.00	180.00	90.00
S5678	068	0		29	10	S5678_068_0	2	5	2	1	Specialty	010010		1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	25									25					25			25			25	Specialty																					
S5715	001	0		29	10	S5715_001_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				44.00	110.00		44.00	132.00		44.00			110.00								44.00
S5715	001	0		29	10	S5715_001_0	2	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				73.00	182.50		73.00	219.00		73.00			182.50								73.00
S5715	001	0		29	10	S5715_001_0	2	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00			22.50								9.00
S5715	001	0		29	10	S5715_001_0	2	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	002	0		29	10	S5715_002_0	2	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	002	0		29	10	S5715_002_0	2	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
S5715	002	0		29	10	S5715_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				38.00	95.00		38.00	114.00		38.00			95.00								38.00
S5715	002	0		29	10	S5715_002_0	2	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	002	0		29	10	S5715_002_0	2	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5715	002	0		29	10	S5715_002_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5715	002	0		29	10	S5715_002_0	2	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	002	0		29	10	S5715_002_0	2	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	003	0		29	10	S5715_003_0	2	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				10.00	25.00		10.00	30.00		10.00			25.00								10.00
S5715	003	0		29	10	S5715_003_0	2	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				79.00	197.50		79.00	237.00		79.00			197.50								79.00
S5715	003	0		29	10	S5715_003_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00
S5715	003	0		29	10	S5715_003_0	2	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	004	0		29	10	S5715_004_0	2	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5715	004	0		29	10	S5715_004_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5715	004	0		29	10	S5715_004_0	2	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	004	0		29	10	S5715_004_0	2	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	004	0		29	10	S5715_004_0	2	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
S5715	004	0		29	10	S5715_004_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				38.00	95.00		38.00	114.00		38.00			95.00								38.00
S5715	004	0		29	10	S5715_004_0	2	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	004	0		29	10	S5715_004_0	2	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	005	0		29	10	S5715_005_0	1	3	3	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				75.00	187.50		75.00	225.00		75.00			187.50								75.00
S5715	005	0		29	10	S5715_005_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00
S5715	005	0		29	10	S5715_005_0	1	1	3	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00			22.50								9.00
S5715	005	0		29	10	S5715_005_0	1	4	3	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	006	0		29	10	S5715_006_0	2	1	4	3	Generic	010000	1	2	1		1	Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	006	0		29	10	S5715_006_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5715	006	0		29	10	S5715_006_0	2	3	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5715	006	0		29	10	S5715_006_0	2	4	4	1	Specialty	010010	1	1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	006	0		29	10	S5715_006_0	2	3	4	1	Brand	000010	1	2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				60.00	150.00		60.00	180.00		60.00			150.00								60.00
S5715	006	0		29	10	S5715_006_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				38.00	95.00		38.00	114.00		38.00			95.00								38.00
S5715	006	0		29	10	S5715_006_0	2	1	4	1	Generic	010000	1	2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00
S5715	006	0		29	10	S5715_006_0	2	4	4	3	Specialty	010010	1	1	1	01000000	2	Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				30	30		30	30		30											30	Specialty																					
S5715	007	0		29	10	S5715_007_0	2	1	2	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				2.00	5.00		2.00	6.00		2.00			5.00								2.00
S5715	007	0		29	10	S5715_007_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				33.00	82.50		33.00	99.00		33.00			82.50								33.00
S5715	007	0		29	10	S5715_007_0	2	3	2	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				63.00	157.50		63.00	189.00		63.00			157.50								63.00
S5715	007	0		29	10	S5715_007_0	2	4	2	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				25	25		25	25		25											25	Specialty																					
S5715	008	0		29	10	S5715_008_0	1	1	2	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				2.00	5.00		2.00	6.00		2.00			5.00								2.00
S5715	008	0		29	10	S5715_008_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				32.00	80.00		32.00	96.00		32.00			80.00								32.00
S5715	008	0		29	10	S5715_008_0	1	4	2	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				25	25		25	25		25											25	Specialty																					
S5715	008	0		29	10	S5715_008_0	1	3	2	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				62.00	155.00		62.00	186.00		62.00			155.00								62.00
S5715	009	0		29	10	S5715_009_0	1	1	2	1	Generic	010000		2				Generic	100011011010010000000				30	90		30	90		30										90	31	Generic	2	2	Generic																						Generic				2.00	5.00		2.00	6.00		2.00			5.00								2.00
S5715	009	0		29	10	S5715_009_0	1	3	2	1	Brand	000010		2				Brand	100011011010010000000				30	90		30	90		30										90	31	Brand	2	2	Brand																						Brand				66.00	165.00		66.00	198.00		66.00			165.00								66.00
S5715	009	0		29	10	S5715_009_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	100011011010010000000				30	90		30	90		30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand				36.00	90.00		36.00	108.00		36.00			90.00								36.00
S5715	009	0		29	10	S5715_009_0	1	4	2	1	Specialty	010010		1				Specialty	100011011010000000000				30	90		30	90		30											31	Specialty	2	1	Specialty				25	25		25	25		25											25	Specialty																					
S5726	013	0		29	10	S5726_013_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5726	013	0		29	10	S5726_013_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5726	013	0		29	10	S5726_013_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5726	013	0		29	10	S5726_013_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00								7.00						10.50			21.00		7.00
S5726	013	0		29	10	S5726_013_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.00	132.00								44.00						110.00			132.00		44.00
S5726	014	0		29	10	S5726_014_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5726	014	0		29	10	S5726_014_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5726	014	0		29	10	S5726_014_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5726	014	0		29	10	S5726_014_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5726	014	0		29	10	S5726_014_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5726	015	0		29	10	S5726_015_0	3	1	4	1	Tier 1 Preferred Generic	001000	3	2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5726	015	0		29	10	S5726_015_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2			Tier 5 Specialty																							Tier 5 Specialty			Tier 5 Specialty																						Tier 5 Specialty																					
S5726	015	0		29	10	S5726_015_0	3	4	4	3	Tier 4 Non-Specialty Injectable	010010	1	2	2			Tier 4 Non-Specialty Injectable																							Tier 4 Non-Specialty Injectable			Tier 4 Non-Specialty Injectable																						Tier 4 Non-Specialty Injectable																					
S5726	015	0		29	10	S5726_015_0	3	3	4	3	Tier 3 Non-Preferred Brand or Generic	100100	1	2	2			Tier 3 Non-Preferred Brand or Generic																							Tier 3 Non-Preferred Brand or Generic			Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic																					
S5726	015	0		29	10	S5726_015_0	3	2	4	3	Tier 2 Preferred Brand	000001	1	2	2			Tier 2 Preferred Brand																							Tier 2 Preferred Brand			Tier 2 Preferred Brand																						Tier 2 Preferred Brand																					
S5726	015	0		29	10	S5726_015_0	3	1	4	3	Tier 1 Preferred Generic	001000	3	2	1		1	Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5726	015	0		29	10	S5726_015_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33					33			33			33	Tier 5 Specialty																					
S5726	015	0		29	10	S5726_015_0	3	2	4	1	Tier 2 Preferred Brand	000001	1	2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00
S5726	015	0		29	10	S5726_015_0	3	3	4	1	Tier 3 Non-Preferred Brand or Generic	100100	1	2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	75.00	225.00								75.00						187.50			225.00		75.00
S5726	015	0		29	10	S5726_015_0	3	4	4	1	Tier 4 Non-Specialty Injectable	010010	1	2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable																					
S5741	001	0		29	10	S5741_001_0	3	4	2	1	Tier 4	010010		1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
S5741	001	0		29	10	S5741_001_0	3	3	2	1	Tier 3	100100		2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																					
S5741	001	0		29	10	S5741_001_0	3	1	2	1	Tier 1	001000		2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
S5741	001	0		29	10	S5741_001_0	3	2	2	1	Tier 2	000001		2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																					
S5741	003	0		29	10	S5741_003_0	2	1	4	1	Tier 1	001000	1	2				Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
S5741	003	0		29	10	S5741_003_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 2	2	2	Tier 2																						Tier 2				25.00	50.00	75.00	25.00	75.00	75.00	25.00		25.00	50.00	50.00							25.00
S5741	003	0		29	10	S5741_003_0	2	3	4	1	Tier 3	100100	1	2				Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 3	2	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																					
S5741	003	0		29	10	S5741_003_0	2	4	4	1	Tier 4	010010	1	1				Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 4	2	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																					
S5741	003	0		29	10	S5741_003_0	2	1	4	3	Tier 1	001000	1	2	1		1	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	60							90	31	Tier 1	2	2	Tier 1																						Tier 1				5.00	10.00	15.00	5.00	15.00	15.00	5.00		5.00	10.00	10.00							5.00
S5741	003	0		29	10	S5741_003_0	2	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5741	003	0		29	10	S5741_003_0	2	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5741	003	0		29	10	S5741_003_0	2	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5743	001	0		29	10	S5743_001_0	2	1	2	1	Level 1: Covered Generic	010000		2				Level 1: Covered Generic	111000000010010000000	31	90								31										90	31	Level 1: Covered Generic	2	1	Level 1: Covered Generic	10	10								10			10								10	Level 1: Covered Generic																					
S5743	001	0		29	10	S5743_001_0	2	4	2	1	Covered Specialty	110011		1				Covered Specialty	111000000010010000000	31	90								31										90	31	Covered Specialty	2	1	Covered Specialty	25	25								25			25								25	Covered Specialty																					
S5743	001	0		29	10	S5743_001_0	2	3	2	1	Level 3: Covered Brand	100000		2				Level 3: Covered Brand	111000000010010000000	31	90								31										90	31	Level 3: Covered Brand	2	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																					
S5743	001	0		29	10	S5743_001_0	2	2	2	1	Level 2: Covered Preferred Brand	000001		2				Level 2: Covered Preferred Brand	111000000010010000000	31	90								31										90	31	Level 2: Covered Preferred Brand	2	1	Level 2: Covered Preferred Brand	22	22								22			22								22	Level 2: Covered Preferred Brand																					
S5743	003	0		29	10	S5743_003_0	5	4	4	1	Covered Specialty	110011	1	1				Covered Specialty	111000000010010000000	31	90								31										90	31	Covered Specialty	2	1	Covered Specialty	33	33								33			33								33	Covered Specialty																					
S5743	003	0		29	10	S5743_003_0	5	2	4	1	Level 2: Covered Preferred Brand	000001	1	2				Level 2: Covered Preferred Brand	111000000010010000000	31	90								31										90	31	Level 2: Covered Preferred Brand	2	2	Level 2: Covered Preferred Brand																						Level 2: Covered Preferred Brand	32.00	96.00								32.00			64.00								32.00
S5743	003	0		29	10	S5743_003_0	5	1	4	1	Level 1: Covered Generic	010000	1	2				Level 1: Covered Generic	111000000010010000000	31	90								31										90	31	Level 1: Covered Generic	2	2	Level 1: Covered Generic																						Level 1: Covered Generic	4.00	12.00								4.00			8.00								4.00
S5743	003	0		29	10	S5743_003_0	5	3	4	1	Level 3: Covered Brand	100000	1	2				Level 3: Covered Brand	111000000010010000000	31	90								31										90	31	Level 3: Covered Brand	2	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																					
S5743	004	0		29	10	S5743_004_0	5	4	4	3	Covered Specialty	110011	1	1	2			Covered Specialty																							Covered Specialty			Covered Specialty																						Covered Specialty																					
S5743	004	0		29	10	S5743_004_0	5	3	4	3	Level 3: Covered Brand	100000	1	2	2			Level 3: Covered Brand																							Level 3: Covered Brand			Level 3: Covered Brand																						Level 3: Covered Brand																					
S5743	004	0		29	10	S5743_004_0	5	2	4	3	Level 2: Covered Preferred Brand	000001	1	2	2			Level 2: Covered Preferred Brand																							Level 2: Covered Preferred Brand			Level 2: Covered Preferred Brand																						Level 2: Covered Preferred Brand																					
S5743	004	0		29	10	S5743_004_0	5	1	4	3	Level 1: Covered Generic	010000	1	2	1		1	Level 1: Covered Generic	111000000010010000000	31	90								31										90	31	Level 1: Covered Generic	2	2	Level 1: Covered Generic																						Level 1: Covered Generic	3.00	9.00								3.00			6.00								3.00
S5743	004	0		29	10	S5743_004_0	5	4	4	1	Covered Specialty	110011	1	1				Covered Specialty	111000000010010000000	31	90								31										90	31	Covered Specialty	2	1	Covered Specialty	33	33								33			33								33	Covered Specialty																					
S5743	004	0		29	10	S5743_004_0	5	3	4	1	Level 3: Covered Brand	100000	1	2				Level 3: Covered Brand	111000000010010000000	31	90								31										90	31	Level 3: Covered Brand	2	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																					
S5743	004	0		29	10	S5743_004_0	5	2	4	1	Level 2: Covered Preferred Brand	000001	1	2				Level 2: Covered Preferred Brand	111000000010010000000	31	90								31										90	31	Level 2: Covered Preferred Brand	2	2	Level 2: Covered Preferred Brand																						Level 2: Covered Preferred Brand	37.00	111.00								37.00			74.00								37.00
S5743	004	0		29	10	S5743_004_0	5	1	4	1	Level 1: Covered Generic	010000	1	2				Level 1: Covered Generic	111000000010010000000	31	90								31										90	31	Level 1: Covered Generic	2	2	Level 1: Covered Generic																						Level 1: Covered Generic	3.00	9.00								3.00			6.00								3.00
S5753	006	0		29	10	S5753_006_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010110000000	30	90	60							30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00	114.00							57.00		57.00	142.50								57.00
S5753	006	0		29	10	S5753_006_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00		37.00	92.50								37.00
S5753	006	0		29	10	S5753_006_0	6	1	4	1	Generic	010000	1	2				Generic	111100000010110000000	30	90	60							30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	17.50								7.00
S5753	006	0		29	10	S5753_006_0	6	4	4	1	Specialty Brand	000010	1	1				Specialty Brand	111100000010110000000	30	90	60							30		30								90	31	Specialty Brand	2	1	Specialty Brand	33	33	33							33		33	33								33	Specialty Brand																					
S5753	007	0		29	10	S5753_007_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111100000010110000000	30	90	60							30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	17.50								7.00
S5753	007	0		29	10	S5753_007_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5753	007	0		29	10	S5753_007_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5753	007	0		29	10	S5753_007_0	6	4	4	1	Specialty Brand	000010	1	1				Specialty Brand	111100000010110000000	30	90	60							30		30								90	31	Specialty Brand	2	1	Specialty Brand	33	33	33							33		33	33								33	Specialty Brand																					
S5753	007	0		29	10	S5753_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111100000010110000000	30	90	60							30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	57.00	171.00	114.00							57.00		57.00	142.50								57.00
S5753	007	0		29	10	S5753_007_0	6	4	4	3	Specialty Brand	000010	1	1	2			Specialty Brand																							Specialty Brand			Specialty Brand																						Specialty Brand																					
S5753	007	0		29	10	S5753_007_0	6	1	4	1	Generic	010000	1	2				Generic	111100000010110000000	30	90	60							30		30								90	31	Generic	2	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	17.50								7.00
S5753	007	0		29	10	S5753_007_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00	74.00							37.00		37.00	92.50								37.00
S5755	005	0		29	10	S5755_005_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	005	0		29	10	S5755_005_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	005	0		29	10	S5755_005_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	005	0		29	10	S5755_005_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	006	0		29	10	S5755_006_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	006	0		29	10	S5755_006_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	006	0		29	10	S5755_006_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	006	0		29	10	S5755_006_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	007	0		29	10	S5755_007_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	007	0		29	10	S5755_007_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	007	0		29	10	S5755_007_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	007	0		29	10	S5755_007_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	008	0		29	10	S5755_008_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	008	0		29	10	S5755_008_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	008	0		29	10	S5755_008_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	008	0		29	10	S5755_008_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	009	0		29	10	S5755_009_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	009	0		29	10	S5755_009_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	009	0		29	10	S5755_009_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	009	0		29	10	S5755_009_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	010	0		29	10	S5755_010_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	010	0		29	10	S5755_010_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	010	0		29	10	S5755_010_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	010	0		29	10	S5755_010_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	011	0		29	10	S5755_011_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	011	0		29	10	S5755_011_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	011	0		29	10	S5755_011_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	011	0		29	10	S5755_011_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	012	0		29	10	S5755_012_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	012	0		29	10	S5755_012_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	012	0		29	10	S5755_012_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	012	0		29	10	S5755_012_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	013	0		29	10	S5755_013_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	013	0		29	10	S5755_013_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	013	0		29	10	S5755_013_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	013	0		29	10	S5755_013_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	014	0		29	10	S5755_014_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	014	0		29	10	S5755_014_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	014	0		29	10	S5755_014_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	014	0		29	10	S5755_014_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	015	0		29	10	S5755_015_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	015	0		29	10	S5755_015_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	015	0		29	10	S5755_015_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	015	0		29	10	S5755_015_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	016	0		29	10	S5755_016_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	016	0		29	10	S5755_016_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	016	0		29	10	S5755_016_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	016	0		29	10	S5755_016_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	017	0		29	10	S5755_017_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	017	0		29	10	S5755_017_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	017	0		29	10	S5755_017_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	017	0		29	10	S5755_017_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	018	0		29	10	S5755_018_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	018	0		29	10	S5755_018_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	018	0		29	10	S5755_018_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	018	0		29	10	S5755_018_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	019	0		29	10	S5755_019_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	019	0		29	10	S5755_019_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	019	0		29	10	S5755_019_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	019	0		29	10	S5755_019_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	020	0		29	10	S5755_020_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	020	0		29	10	S5755_020_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	020	0		29	10	S5755_020_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	020	0		29	10	S5755_020_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	021	0		29	10	S5755_021_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	021	0		29	10	S5755_021_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	021	0		29	10	S5755_021_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	021	0		29	10	S5755_021_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	022	0		29	10	S5755_022_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	022	0		29	10	S5755_022_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	022	0		29	10	S5755_022_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	022	0		29	10	S5755_022_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	023	0		29	10	S5755_023_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	023	0		29	10	S5755_023_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	023	0		29	10	S5755_023_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	023	0		29	10	S5755_023_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	024	0		29	10	S5755_024_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	024	0		29	10	S5755_024_0	2	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	024	0		29	10	S5755_024_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	024	0		29	10	S5755_024_0	2	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	025	0		29	10	S5755_025_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	025	0		29	10	S5755_025_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	025	0		29	10	S5755_025_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	025	0		29	10	S5755_025_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	026	0		29	10	S5755_026_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	026	0		29	10	S5755_026_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	026	0		29	10	S5755_026_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	026	0		29	10	S5755_026_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	027	0		29	10	S5755_027_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	027	0		29	10	S5755_027_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	027	0		29	10	S5755_027_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	027	0		29	10	S5755_027_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	028	0		29	10	S5755_028_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	028	0		29	10	S5755_028_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	028	0		29	10	S5755_028_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	028	0		29	10	S5755_028_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	029	0		29	10	S5755_029_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	029	0		29	10	S5755_029_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	029	0		29	10	S5755_029_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	029	0		29	10	S5755_029_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	030	0		29	10	S5755_030_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	030	0		29	10	S5755_030_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	030	0		29	10	S5755_030_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	030	0		29	10	S5755_030_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	031	0		29	10	S5755_031_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	031	0		29	10	S5755_031_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	031	0		29	10	S5755_031_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	031	0		29	10	S5755_031_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	032	0		29	10	S5755_032_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	80.00								32.00			64.00								32.00
S5755	032	0		29	10	S5755_032_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	032	0		29	10	S5755_032_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	64.00	160.00								64.00			128.00								64.00
S5755	032	0		29	10	S5755_032_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00
S5755	033	0		29	10	S5755_033_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	033	0		29	10	S5755_033_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	033	0		29	10	S5755_033_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	033	0		29	10	S5755_033_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	034	0		29	10	S5755_034_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00
S5755	034	0		29	10	S5755_034_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	33.00	83.00								33.00			66.00								33.00
S5755	034	0		29	10	S5755_034_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	034	0		29	10	S5755_034_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	165.00								66.00			132.00								66.00
S5755	035	0		29	10	S5755_035_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	035	0		29	10	S5755_035_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			140.00								70.00
S5755	035	0		29	10	S5755_035_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	88.00								35.00			70.00								35.00
S5755	035	0		29	10	S5755_035_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00
S5755	038	0		29	10	S5755_038_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	038	0		29	10	S5755_038_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	038	0		29	10	S5755_038_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	038	0		29	10	S5755_038_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	039	0		29	10	S5755_039_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	5.00	14.00								5.00			13.00								5.00
S5755	039	0		29	10	S5755_039_0	1	2	4	1	Preferred Brand	010001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	78.00								31.00			62.00								31.00
S5755	039	0		29	10	S5755_039_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5755	039	0		29	10	S5755_039_0	1	3	4	1	Non-Preferred Brand	110000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	62.00	155.00								62.00			124.00								62.00
S5755	040	0		29	10	S5755_040_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	040	0		29	10	S5755_040_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	040	0		29	10	S5755_040_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	040	0		29	10	S5755_040_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	041	0		29	10	S5755_041_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	041	0		29	10	S5755_041_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	041	0		29	10	S5755_041_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	041	0		29	10	S5755_041_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	042	0		29	10	S5755_042_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	042	0		29	10	S5755_042_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	042	0		29	10	S5755_042_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	042	0		29	10	S5755_042_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	043	0		29	10	S5755_043_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	043	0		29	10	S5755_043_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	043	0		29	10	S5755_043_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	043	0		29	10	S5755_043_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	044	0		29	10	S5755_044_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	044	0		29	10	S5755_044_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	044	0		29	10	S5755_044_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	044	0		29	10	S5755_044_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	045	0		29	10	S5755_045_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	045	0		29	10	S5755_045_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	045	0		29	10	S5755_045_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	045	0		29	10	S5755_045_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	046	0		29	10	S5755_046_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	046	0		29	10	S5755_046_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	046	0		29	10	S5755_046_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	046	0		29	10	S5755_046_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	047	0		29	10	S5755_047_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	047	0		29	10	S5755_047_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	047	0		29	10	S5755_047_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	047	0		29	10	S5755_047_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	048	0		29	10	S5755_048_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	048	0		29	10	S5755_048_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	048	0		29	10	S5755_048_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	048	0		29	10	S5755_048_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	049	0		29	10	S5755_049_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	049	0		29	10	S5755_049_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	049	0		29	10	S5755_049_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	049	0		29	10	S5755_049_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	050	0		29	10	S5755_050_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	050	0		29	10	S5755_050_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	050	0		29	10	S5755_050_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	050	0		29	10	S5755_050_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	051	0		29	10	S5755_051_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	051	0		29	10	S5755_051_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	051	0		29	10	S5755_051_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	051	0		29	10	S5755_051_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	052	0		29	10	S5755_052_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	052	0		29	10	S5755_052_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	052	0		29	10	S5755_052_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	052	0		29	10	S5755_052_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	053	0		29	10	S5755_053_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	053	0		29	10	S5755_053_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	053	0		29	10	S5755_053_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	053	0		29	10	S5755_053_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	054	0		29	10	S5755_054_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	054	0		29	10	S5755_054_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	054	0		29	10	S5755_054_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	054	0		29	10	S5755_054_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	055	0		29	10	S5755_055_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	055	0		29	10	S5755_055_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	055	0		29	10	S5755_055_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	055	0		29	10	S5755_055_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	056	0		29	10	S5755_056_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	056	0		29	10	S5755_056_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	056	0		29	10	S5755_056_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	056	0		29	10	S5755_056_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	057	0		29	10	S5755_057_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	057	0		29	10	S5755_057_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	057	0		29	10	S5755_057_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	057	0		29	10	S5755_057_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	058	0		29	10	S5755_058_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	058	0		29	10	S5755_058_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	058	0		29	10	S5755_058_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	058	0		29	10	S5755_058_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	059	0		29	10	S5755_059_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	059	0		29	10	S5755_059_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	059	0		29	10	S5755_059_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	059	0		29	10	S5755_059_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	060	0		29	10	S5755_060_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	060	0		29	10	S5755_060_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	060	0		29	10	S5755_060_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	060	0		29	10	S5755_060_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	061	0		29	10	S5755_061_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	061	0		29	10	S5755_061_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	061	0		29	10	S5755_061_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	061	0		29	10	S5755_061_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	062	0		29	10	S5755_062_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	062	0		29	10	S5755_062_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	062	0		29	10	S5755_062_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	062	0		29	10	S5755_062_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	063	0		29	10	S5755_063_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	063	0		29	10	S5755_063_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	063	0		29	10	S5755_063_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	063	0		29	10	S5755_063_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	064	0		29	10	S5755_064_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	064	0		29	10	S5755_064_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	064	0		29	10	S5755_064_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	064	0		29	10	S5755_064_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	065	0		29	10	S5755_065_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	065	0		29	10	S5755_065_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	065	0		29	10	S5755_065_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	065	0		29	10	S5755_065_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	066	0		29	10	S5755_066_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	066	0		29	10	S5755_066_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	066	0		29	10	S5755_066_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	066	0		29	10	S5755_066_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	067	0		29	10	S5755_067_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	067	0		29	10	S5755_067_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	067	0		29	10	S5755_067_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	067	0		29	10	S5755_067_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	068	0		29	10	S5755_068_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	068	0		29	10	S5755_068_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	068	0		29	10	S5755_068_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	068	0		29	10	S5755_068_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	069	0		29	10	S5755_069_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	069	0		29	10	S5755_069_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	069	0		29	10	S5755_069_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	069	0		29	10	S5755_069_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	070	0		29	10	S5755_070_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	070	0		29	10	S5755_070_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	070	0		29	10	S5755_070_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	070	0		29	10	S5755_070_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	071	0		29	10	S5755_071_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	071	0		29	10	S5755_071_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	071	0		29	10	S5755_071_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5755	071	0		29	10	S5755_071_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	072	0		29	10	S5755_072_0	1	4	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5755	072	0		29	10	S5755_072_0	1	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00
S5755	072	0		29	10	S5755_072_0	1	2	3	1	Preferred Brand	010001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00
S5755	072	0		29	10	S5755_072_0	1	3	3	1	Non-Preferred Brand	110000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S5766	002	0		29	10	S5766_002_0	4	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	34	90								34											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	132.00								66.00											66.00
S5766	002	0		29	10	S5766_002_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	34	90								34											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00											28.00
S5766	002	0		29	10	S5766_002_0	4	1	3	1	Generic	010000		2				Generic	111000000010000000000	34	90								34											34	Generic	2	2	Generic																						Generic	9.00	18.00								9.00											9.00
S5766	002	0		29	10	S5766_002_0	4	4	3	1	Non-Self-Administered Medical Injectables	010010		2				Non-Self-Administered Medical Injectables	111000000010000000000	34	90								34											34	Non-Self-Administered Medical Injectables	2	1	Non-Self-Administered Medical Injectables	25	25								25											25	Non-Self-Administered Medical Injectables																					
S5766	003	0		29	10	S5766_003_0	5	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	34	90								34											34	Generic	2	2	Generic																						Generic	9.00	18.00								9.00											9.00
S5766	003	0		29	10	S5766_003_0	5	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5766	003	0		29	10	S5766_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5766	003	0		29	10	S5766_003_0	5	4	4	1	Non-Self-Administered Medical Injectables	010010	1	2				Non-Self-Administered Medical Injectables	111000000010000000000	34	90								34											34	Non-Self-Administered Medical Injectables	2	1	Non-Self-Administered Medical Injectables	25	25								25											25	Non-Self-Administered Medical Injectables																					
S5766	003	0		29	10	S5766_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	34	90								34											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	66.00	132.00								66.00											66.00
S5766	003	0		29	10	S5766_003_0	5	4	4	3	Non-Self-Administered Medical Injectables	010010	1	2	2			Non-Self-Administered Medical Injectables																							Non-Self-Administered Medical Injectables			Non-Self-Administered Medical Injectables																						Non-Self-Administered Medical Injectables																					
S5766	003	0		29	10	S5766_003_0	5	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	34	90								34											34	Generic	2	2	Generic																						Generic	9.00	18.00								9.00											9.00
S5766	003	0		29	10	S5766_003_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	34	90								34											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	56.00								28.00											28.00
S5768	005	0		29	10	S5768_005_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	005	0		29	10	S5768_005_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	005	0		29	10	S5768_005_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00											59.00
S5768	005	0		29	10	S5768_005_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	007	0		29	10	S5768_007_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	007	0		29	10	S5768_007_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5768	007	0		29	10	S5768_007_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	007	0		29	10	S5768_007_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	008	0		29	10	S5768_008_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00											58.00
S5768	008	0		29	10	S5768_008_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	008	0		29	10	S5768_008_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00											29.00
S5768	008	0		29	10	S5768_008_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00											5.00
S5768	009	0		29	10	S5768_009_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	009	0		29	10	S5768_009_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5768	009	0		29	10	S5768_009_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	009	0		29	10	S5768_009_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	010	0		29	10	S5768_010_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00											62.00
S5768	010	0		29	10	S5768_010_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	010	0		29	10	S5768_010_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	010	0		29	10	S5768_010_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	012	0		29	10	S5768_012_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	012	0		29	10	S5768_012_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00											59.00
S5768	012	0		29	10	S5768_012_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00											29.00
S5768	012	0		29	10	S5768_012_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	015	0		29	10	S5768_015_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5768	015	0		29	10	S5768_015_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	015	0		29	10	S5768_015_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00											28.00
S5768	015	0		29	10	S5768_015_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	016	0		29	10	S5768_016_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	016	0		29	10	S5768_016_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	54.00	162.00								54.00											54.00
S5768	016	0		29	10	S5768_016_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	016	0		29	10	S5768_016_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	017	0		29	10	S5768_017_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	56.00	168.00								56.00											56.00
S5768	017	0		29	10	S5768_017_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	017	0		29	10	S5768_017_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00											29.00
S5768	017	0		29	10	S5768_017_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	018	0		29	10	S5768_018_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	018	0		29	10	S5768_018_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5768	018	0		29	10	S5768_018_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00											58.00
S5768	018	0		29	10	S5768_018_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	021	0		29	10	S5768_021_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	021	0		29	10	S5768_021_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	021	0		29	10	S5768_021_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	51.00	153.00								51.00											51.00
S5768	021	0		29	10	S5768_021_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	031	0		29	10	S5768_031_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	031	0		29	10	S5768_031_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00											25.00
S5768	031	0		29	10	S5768_031_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00											67.00
S5768	031	0		29	10	S5768_031_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	038	0		29	10	S5768_038_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	038	0		29	10	S5768_038_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	038	0		29	10	S5768_038_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	038	0		29	10	S5768_038_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	53.00	159.00								53.00											53.00
S5768	039	0		29	10	S5768_039_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	039	0		29	10	S5768_039_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00											59.00
S5768	039	0		29	10	S5768_039_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00											28.00
S5768	039	0		29	10	S5768_039_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	040	0		29	10	S5768_040_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00											64.00
S5768	040	0		29	10	S5768_040_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5768	040	0		29	10	S5768_040_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	040	0		29	10	S5768_040_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	041	0		29	10	S5768_041_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	51.00	153.00								51.00											51.00
S5768	041	0		29	10	S5768_041_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00											25.00
S5768	041	0		29	10	S5768_041_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	041	0		29	10	S5768_041_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	042	0		29	10	S5768_042_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	042	0		29	10	S5768_042_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	93.00								31.00											31.00
S5768	042	0		29	10	S5768_042_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	61.00	183.00								61.00											61.00
S5768	042	0		29	10	S5768_042_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	043	0		29	10	S5768_043_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	043	0		29	10	S5768_043_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	31.00	93.00								31.00											31.00
S5768	043	0		29	10	S5768_043_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	65.00	195.00								65.00											65.00
S5768	043	0		29	10	S5768_043_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	044	0		29	10	S5768_044_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	044	0		29	10	S5768_044_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	044	0		29	10	S5768_044_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	044	0		29	10	S5768_044_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5768	045	0		29	10	S5768_045_0	3	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	67.00	201.00								67.00											67.00
S5768	045	0		29	10	S5768_045_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00											32.00
S5768	045	0		29	10	S5768_045_0	3	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00											6.00
S5768	045	0		29	10	S5768_045_0	3	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	046	0		29	10	S5768_046_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00											60.00
S5768	046	0		29	10	S5768_046_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5768	046	0		29	10	S5768_046_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	046	0		29	10	S5768_046_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	047	0		29	10	S5768_047_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	047	0		29	10	S5768_047_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00											29.00
S5768	047	0		29	10	S5768_047_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00											59.00
S5768	047	0		29	10	S5768_047_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	048	0		29	10	S5768_048_0	2	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	048	0		29	10	S5768_048_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	59.00	177.00								59.00											59.00
S5768	048	0		29	10	S5768_048_0	2	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00											29.00
S5768	048	0		29	10	S5768_048_0	2	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	082	0		29	10	S5768_082_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00											64.00
S5768	082	0		29	10	S5768_082_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	082	0		29	10	S5768_082_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	082	0		29	10	S5768_082_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	083	0		29	10	S5768_083_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	083	0		29	10	S5768_083_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	083	0		29	10	S5768_083_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	52.00	156.00								52.00											52.00
S5768	083	0		29	10	S5768_083_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	084	0		29	10	S5768_084_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	084	0		29	10	S5768_084_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	084	0		29	10	S5768_084_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	084	0		29	10	S5768_084_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	085	0		29	10	S5768_085_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	085	0		29	10	S5768_085_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	085	0		29	10	S5768_085_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	085	0		29	10	S5768_085_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	086	0		29	10	S5768_086_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	086	0		29	10	S5768_086_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	086	0		29	10	S5768_086_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	086	0		29	10	S5768_086_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	087	0		29	10	S5768_087_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	47.00	141.00								47.00											47.00
S5768	087	0		29	10	S5768_087_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	087	0		29	10	S5768_087_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	087	0		29	10	S5768_087_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	088	0		29	10	S5768_088_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	088	0		29	10	S5768_088_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	088	0		29	10	S5768_088_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	088	0		29	10	S5768_088_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	089	0		29	10	S5768_089_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	089	0		29	10	S5768_089_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	089	0		29	10	S5768_089_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	089	0		29	10	S5768_089_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	090	0		29	10	S5768_090_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	090	0		29	10	S5768_090_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	090	0		29	10	S5768_090_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	49.00	147.00								49.00											49.00
S5768	090	0		29	10	S5768_090_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	091	0		29	10	S5768_091_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	091	0		29	10	S5768_091_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	091	0		29	10	S5768_091_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	091	0		29	10	S5768_091_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	092	0		29	10	S5768_092_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	092	0		29	10	S5768_092_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	46.00	138.00								46.00											46.00
S5768	092	0		29	10	S5768_092_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	092	0		29	10	S5768_092_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	093	0		29	10	S5768_093_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	093	0		29	10	S5768_093_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	093	0		29	10	S5768_093_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	093	0		29	10	S5768_093_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	094	0		29	10	S5768_094_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	094	0		29	10	S5768_094_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	094	0		29	10	S5768_094_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	094	0		29	10	S5768_094_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	095	0		29	10	S5768_095_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	095	0		29	10	S5768_095_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	095	0		29	10	S5768_095_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	095	0		29	10	S5768_095_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	096	0		29	10	S5768_096_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	096	0		29	10	S5768_096_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	46.00	138.00								46.00											46.00
S5768	096	0		29	10	S5768_096_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	096	0		29	10	S5768_096_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	097	0		29	10	S5768_097_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	097	0		29	10	S5768_097_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	097	0		29	10	S5768_097_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	097	0		29	10	S5768_097_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	45.00	135.00								45.00											45.00
S5768	098	0		29	10	S5768_098_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	098	0		29	10	S5768_098_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	098	0		29	10	S5768_098_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	098	0		29	10	S5768_098_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	49.00	147.00								49.00											49.00
S5768	099	0		29	10	S5768_099_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	099	0		29	10	S5768_099_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	099	0		29	10	S5768_099_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	49.00	147.00								49.00											49.00
S5768	099	0		29	10	S5768_099_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	100	0		29	10	S5768_100_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	100	0		29	10	S5768_100_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	100	0		29	10	S5768_100_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	100	0		29	10	S5768_100_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	101	0		29	10	S5768_101_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	101	0		29	10	S5768_101_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	101	0		29	10	S5768_101_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	101	0		29	10	S5768_101_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	46.00	138.00								46.00											46.00
S5768	102	0		29	10	S5768_102_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	102	0		29	10	S5768_102_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	45.00	135.00								45.00											45.00
S5768	102	0		29	10	S5768_102_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	102	0		29	10	S5768_102_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	103	0		29	10	S5768_103_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	103	0		29	10	S5768_103_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	103	0		29	10	S5768_103_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	47.00	141.00								47.00											47.00
S5768	103	0		29	10	S5768_103_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	104	0		29	10	S5768_104_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	104	0		29	10	S5768_104_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	104	0		29	10	S5768_104_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	104	0		29	10	S5768_104_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	105	0		29	10	S5768_105_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	105	0		29	10	S5768_105_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	105	0		29	10	S5768_105_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	46.00	138.00								46.00											46.00
S5768	105	0		29	10	S5768_105_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	106	0		29	10	S5768_106_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	106	0		29	10	S5768_106_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	106	0		29	10	S5768_106_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	106	0		29	10	S5768_106_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	107	0		29	10	S5768_107_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	107	0		29	10	S5768_107_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	107	0		29	10	S5768_107_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	107	0		29	10	S5768_107_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	108	0		29	10	S5768_108_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	108	0		29	10	S5768_108_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	108	0		29	10	S5768_108_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	108	0		29	10	S5768_108_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	47.00	141.00								47.00											47.00
S5768	109	0		29	10	S5768_109_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	109	0		29	10	S5768_109_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	109	0		29	10	S5768_109_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	22.00	66.00								22.00											22.00
S5768	109	0		29	10	S5768_109_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	110	0		29	10	S5768_110_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	110	0		29	10	S5768_110_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	110	0		29	10	S5768_110_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	110	0		29	10	S5768_110_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	111	0		29	10	S5768_111_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	111	0		29	10	S5768_111_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	111	0		29	10	S5768_111_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	111	0		29	10	S5768_111_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	112	0		29	10	S5768_112_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	112	0		29	10	S5768_112_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	112	0		29	10	S5768_112_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	112	0		29	10	S5768_112_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	113	0		29	10	S5768_113_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	113	0		29	10	S5768_113_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	45.00	135.00								45.00											45.00
S5768	113	0		29	10	S5768_113_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	113	0		29	10	S5768_113_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	114	0		29	10	S5768_114_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	114	0		29	10	S5768_114_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	22.00	66.00								22.00											22.00
S5768	114	0		29	10	S5768_114_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	114	0		29	10	S5768_114_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	115	0		29	10	S5768_115_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	115	0		29	10	S5768_115_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	48.00	144.00								48.00											48.00
S5768	115	0		29	10	S5768_115_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	115	0		29	10	S5768_115_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00											4.00
S5768	116	0		29	10	S5768_116_0	2	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	50.00	150.00								50.00											50.00
S5768	116	0		29	10	S5768_116_0	2	4	4	1	Specialty-Generic and Brand	010010	1	1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	28									28											28	Specialty-Generic and Brand																					
S5768	116	0		29	10	S5768_116_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00											20.00
S5768	116	0		29	10	S5768_116_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00											3.00
S5768	117	0		29	10	S5768_117_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	117	0		29	10	S5768_117_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	117	0		29	10	S5768_117_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00											64.00
S5768	117	0		29	10	S5768_117_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	118	0		29	10	S5768_118_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	118	0		29	10	S5768_118_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00											25.00
S5768	118	0		29	10	S5768_118_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	118	0		29	10	S5768_118_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	53.00	159.00								53.00											53.00
S5768	119	0		29	10	S5768_119_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	119	0		29	10	S5768_119_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	56.00	168.00								56.00											56.00
S5768	119	0		29	10	S5768_119_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	78.00								26.00											26.00
S5768	119	0		29	10	S5768_119_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	120	0		29	10	S5768_120_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	120	0		29	10	S5768_120_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	78.00								26.00											26.00
S5768	120	0		29	10	S5768_120_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00											58.00
S5768	120	0		29	10	S5768_120_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	121	0		29	10	S5768_121_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	121	0		29	10	S5768_121_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	121	0		29	10	S5768_121_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	57.00	171.00								57.00											57.00
S5768	121	0		29	10	S5768_121_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	122	0		29	10	S5768_122_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	122	0		29	10	S5768_122_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00											25.00
S5768	122	0		29	10	S5768_122_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	122	0		29	10	S5768_122_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	54.00	162.00								54.00											54.00
S5768	123	0		29	10	S5768_123_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	123	0		29	10	S5768_123_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	26.00	78.00								26.00											26.00
S5768	123	0		29	10	S5768_123_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	58.00	174.00								58.00											58.00
S5768	123	0		29	10	S5768_123_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5768	124	0		29	10	S5768_124_0	1	1	3	1	Preferred Generic	001000		2				Preferred Generic	111000000010000000000	30	90								30											31	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00											7.00
S5768	124	0		29	10	S5768_124_0	1	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2				Non-Preferred Generic/Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Generic/Non-Preferred Brand	2	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	62.00	186.00								62.00											62.00
S5768	124	0		29	10	S5768_124_0	1	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00											27.00
S5768	124	0		29	10	S5768_124_0	1	4	3	1	Specialty-Generic and Brand	010010		1				Specialty-Generic and Brand	110000000010000000000	30									30											31	Specialty-Generic and Brand	2	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																					
S5775	001	0		29	10	S5775_001_0	6	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010000000000	30	90								30											31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00											50.00
S5775	001	0		29	10	S5775_001_0	6	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010000000000	30	90								30											31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00											25.00
S5775	001	0		29	10	S5775_001_0	6	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010000000000	30	90								30											31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00											3.00
S5775	001	0		29	10	S5775_001_0	6	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010000000000	30	90								30											31	Tier 4	2	1	Tier 4	25	25								25											25	Tier 4																					
S5775	002	0		29	10	S5775_002_0	6	3	3	1	Tier 3	100000		2				Tier 3	111000000010000000000	30	90								30											31	Tier 3	2	2	Tier 3																						Tier 3	60.00	180.00								60.00											60.00
S5775	002	0		29	10	S5775_002_0	6	2	3	1	Tier 2	000001		2				Tier 2	111000000010000000000	30	90								30											31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00											30.00
S5775	002	0		29	10	S5775_002_0	6	1	3	1	Tier 1	010000		2				Tier 1	111000000010000000000	30	90								30											31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00											3.00
S5775	002	0		29	10	S5775_002_0	6	4	3	1	Tier 4	000010		1				Tier 4	111000000010000000000	30	90								30											31	Tier 4	2	1	Tier 4	25	25								25											25	Tier 4																					
S5775	003	0		29	10	S5775_003_0	9	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010000000000	30	90								30											31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00											3.00
S5775	003	0		29	10	S5775_003_0	9	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010000000000	30	90								30											31	Tier 2	2	2	Tier 2																						Tier 2	15.00	45.00								15.00											15.00
S5775	003	0		29	10	S5775_003_0	9	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010000000000	30	90								30											31	Tier 3	2	2	Tier 3																						Tier 3	30.00	90.00								30.00											30.00
S5775	003	0		29	10	S5775_003_0	9	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010000000000	30	90								30											31	Tier 4	2	1	Tier 4	25	25								25											25	Tier 4																					
S5775	003	0		29	10	S5775_003_0	9	1	4	3	Tier 1	010000	1	2	1		1	Tier 1	111000000010000000000	30	90								30											31	Tier 1	2	2	Tier 1																						Tier 1	3.00	9.00								3.00											3.00
S5775	003	0		29	10	S5775_003_0	9	2	4	3	Tier 2	000001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5775	003	0		29	10	S5775_003_0	9	3	4	3	Tier 3	100000	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5775	003	0		29	10	S5775_003_0	9	4	4	3	Tier 4	000010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5795	002	0		29	10	S5795_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
S5795	002	0		29	10	S5795_002_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00		30.00	75.00								30.00
S5795	002	0		29	10	S5795_002_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
S5795	002	0		29	10	S5795_002_0	3	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5795	002	0		29	10	S5795_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5795	002	0		29	10	S5795_002_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5795	002	0		29	10	S5795_002_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
S5795	002	0		29	10	S5795_002_0	3	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S5795	003	0		29	10	S5795_003_0	3	4	3	1	Specialty	000010		1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S5795	003	0		29	10	S5795_003_0	3	3	3	1	Non Preferred Brand	100000		2				Non Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non Preferred Brand	2	2	Non Preferred Brand																						Non Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
S5795	003	0		29	10	S5795_003_0	3	1	3	1	Generic	010000		2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
S5795	003	0		29	10	S5795_003_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00		30.00	75.00								30.00
S5795	006	0		29	10	S5795_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	170.00								68.00		68.00	170.00								68.00
S5795	006	0		29	10	S5795_006_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	75.00								30.00		30.00	75.00								30.00
S5795	006	0		29	10	S5795_006_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00
S5795	006	0		29	10	S5795_006_0	3	4	4	1	Specialty	000010	1	1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	25	25								25		25	25								25	Specialty																					
S5803	070	0		29	10	S5803_070_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	070	0		29	10	S5803_070_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	070	0		29	10	S5803_070_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	071	0		29	10	S5803_071_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	071	0		29	10	S5803_071_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	071	0		29	10	S5803_071_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	072	0		29	10	S5803_072_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	072	0		29	10	S5803_072_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	072	0		29	10	S5803_072_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	40	40								40											40	Non-Preferred Brand																					
S5803	073	0		29	10	S5803_073_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	073	0		29	10	S5803_073_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	073	0		29	10	S5803_073_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	074	0		29	10	S5803_074_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	074	0		29	10	S5803_074_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	074	0		29	10	S5803_074_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	075	0		29	10	S5803_075_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	075	0		29	10	S5803_075_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	075	0		29	10	S5803_075_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	076	0		29	10	S5803_076_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	076	0		29	10	S5803_076_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	076	0		29	10	S5803_076_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	077	0		29	10	S5803_077_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	077	0		29	10	S5803_077_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	077	0		29	10	S5803_077_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	078	0		29	10	S5803_078_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	078	0		29	10	S5803_078_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	078	0		29	10	S5803_078_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	079	0		29	10	S5803_079_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	079	0		29	10	S5803_079_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	079	0		29	10	S5803_079_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	080	0		29	10	S5803_080_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	080	0		29	10	S5803_080_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	080	0		29	10	S5803_080_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	081	0		29	10	S5803_081_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	081	0		29	10	S5803_081_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	081	0		29	10	S5803_081_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	082	0		29	10	S5803_082_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	082	0		29	10	S5803_082_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	082	0		29	10	S5803_082_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	083	0		29	10	S5803_083_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	083	0		29	10	S5803_083_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	083	0		29	10	S5803_083_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	084	0		29	10	S5803_084_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	084	0		29	10	S5803_084_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	084	0		29	10	S5803_084_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	085	0		29	10	S5803_085_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	085	0		29	10	S5803_085_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	085	0		29	10	S5803_085_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	086	0		29	10	S5803_086_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	086	0		29	10	S5803_086_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	086	0		29	10	S5803_086_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	087	0		29	10	S5803_087_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	087	0		29	10	S5803_087_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	087	0		29	10	S5803_087_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	088	0		29	10	S5803_088_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	088	0		29	10	S5803_088_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	088	0		29	10	S5803_088_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	089	0		29	10	S5803_089_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	089	0		29	10	S5803_089_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	089	0		29	10	S5803_089_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	090	0		29	10	S5803_090_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	090	0		29	10	S5803_090_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	090	0		29	10	S5803_090_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	091	0		29	10	S5803_091_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	091	0		29	10	S5803_091_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	091	0		29	10	S5803_091_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	092	0		29	10	S5803_092_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	092	0		29	10	S5803_092_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	092	0		29	10	S5803_092_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	093	0		29	10	S5803_093_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	093	0		29	10	S5803_093_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	093	0		29	10	S5803_093_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	094	0		29	10	S5803_094_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	094	0		29	10	S5803_094_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	094	0		29	10	S5803_094_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	095	0		29	10	S5803_095_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	095	0		29	10	S5803_095_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	095	0		29	10	S5803_095_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	096	0		29	10	S5803_096_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	096	0		29	10	S5803_096_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	096	0		29	10	S5803_096_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	097	0		29	10	S5803_097_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	097	0		29	10	S5803_097_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	097	0		29	10	S5803_097_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	098	0		29	10	S5803_098_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	098	0		29	10	S5803_098_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	098	0		29	10	S5803_098_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																					
S5803	099	0		29	10	S5803_099_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	099	0		29	10	S5803_099_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	099	0		29	10	S5803_099_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	100	0		29	10	S5803_100_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	100	0		29	10	S5803_100_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	100	0		29	10	S5803_100_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	101	0		29	10	S5803_101_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	101	0		29	10	S5803_101_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	101	0		29	10	S5803_101_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	102	0		29	10	S5803_102_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	25	25								25											25	Preferred Brand																					
S5803	102	0		29	10	S5803_102_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																					
S5803	102	0		29	10	S5803_102_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	103	0		29	10	S5803_103_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	103	0		29	10	S5803_103_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	103	0		29	10	S5803_103_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	138	0		29	10	S5803_138_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	138	0		29	10	S5803_138_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	138	0		29	10	S5803_138_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	138	0		29	10	S5803_138_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	139	0		29	10	S5803_139_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	139	0		29	10	S5803_139_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	139	0		29	10	S5803_139_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	139	0		29	10	S5803_139_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	140	0		29	10	S5803_140_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	140	0		29	10	S5803_140_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	140	0		29	10	S5803_140_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	140	0		29	10	S5803_140_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	141	0		29	10	S5803_141_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	141	0		29	10	S5803_141_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	141	0		29	10	S5803_141_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	141	0		29	10	S5803_141_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	142	0		29	10	S5803_142_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	142	0		29	10	S5803_142_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	142	0		29	10	S5803_142_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	142	0		29	10	S5803_142_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	143	0		29	10	S5803_143_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	143	0		29	10	S5803_143_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	143	0		29	10	S5803_143_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	143	0		29	10	S5803_143_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	144	0		29	10	S5803_144_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	144	0		29	10	S5803_144_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	144	0		29	10	S5803_144_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	144	0		29	10	S5803_144_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	145	0		29	10	S5803_145_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	145	0		29	10	S5803_145_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	145	0		29	10	S5803_145_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	145	0		29	10	S5803_145_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	146	0		29	10	S5803_146_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	146	0		29	10	S5803_146_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	146	0		29	10	S5803_146_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	146	0		29	10	S5803_146_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	147	0		29	10	S5803_147_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	147	0		29	10	S5803_147_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	147	0		29	10	S5803_147_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	147	0		29	10	S5803_147_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	148	0		29	10	S5803_148_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	148	0		29	10	S5803_148_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	148	0		29	10	S5803_148_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	148	0		29	10	S5803_148_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	149	0		29	10	S5803_149_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	149	0		29	10	S5803_149_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	149	0		29	10	S5803_149_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	149	0		29	10	S5803_149_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	150	0		29	10	S5803_150_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	150	0		29	10	S5803_150_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	150	0		29	10	S5803_150_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	150	0		29	10	S5803_150_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	151	0		29	10	S5803_151_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	151	0		29	10	S5803_151_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	151	0		29	10	S5803_151_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	151	0		29	10	S5803_151_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	152	0		29	10	S5803_152_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	152	0		29	10	S5803_152_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	152	0		29	10	S5803_152_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	152	0		29	10	S5803_152_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	153	0		29	10	S5803_153_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	153	0		29	10	S5803_153_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	153	0		29	10	S5803_153_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	153	0		29	10	S5803_153_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	154	0		29	10	S5803_154_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	154	0		29	10	S5803_154_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	154	0		29	10	S5803_154_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	154	0		29	10	S5803_154_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	155	0		29	10	S5803_155_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	155	0		29	10	S5803_155_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	155	0		29	10	S5803_155_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	155	0		29	10	S5803_155_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	156	0		29	10	S5803_156_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	156	0		29	10	S5803_156_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	156	0		29	10	S5803_156_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	156	0		29	10	S5803_156_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	157	0		29	10	S5803_157_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	157	0		29	10	S5803_157_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	157	0		29	10	S5803_157_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	157	0		29	10	S5803_157_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	158	0		29	10	S5803_158_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	158	0		29	10	S5803_158_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	158	0		29	10	S5803_158_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	158	0		29	10	S5803_158_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	159	0		29	10	S5803_159_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	159	0		29	10	S5803_159_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	159	0		29	10	S5803_159_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	159	0		29	10	S5803_159_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	160	0		29	10	S5803_160_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	160	0		29	10	S5803_160_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	160	0		29	10	S5803_160_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	160	0		29	10	S5803_160_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	161	0		29	10	S5803_161_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	161	0		29	10	S5803_161_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	161	0		29	10	S5803_161_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	161	0		29	10	S5803_161_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	162	0		29	10	S5803_162_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	162	0		29	10	S5803_162_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	162	0		29	10	S5803_162_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	162	0		29	10	S5803_162_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	163	0		29	10	S5803_163_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	163	0		29	10	S5803_163_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	163	0		29	10	S5803_163_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	163	0		29	10	S5803_163_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	164	0		29	10	S5803_164_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	164	0		29	10	S5803_164_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	164	0		29	10	S5803_164_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	164	0		29	10	S5803_164_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	165	0		29	10	S5803_165_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	165	0		29	10	S5803_165_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	165	0		29	10	S5803_165_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	165	0		29	10	S5803_165_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	166	0		29	10	S5803_166_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	166	0		29	10	S5803_166_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	166	0		29	10	S5803_166_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	166	0		29	10	S5803_166_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	167	0		29	10	S5803_167_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	167	0		29	10	S5803_167_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	167	0		29	10	S5803_167_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	167	0		29	10	S5803_167_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	168	0		29	10	S5803_168_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	168	0		29	10	S5803_168_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	168	0		29	10	S5803_168_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	168	0		29	10	S5803_168_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	169	0		29	10	S5803_169_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	169	0		29	10	S5803_169_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	169	0		29	10	S5803_169_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	169	0		29	10	S5803_169_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	170	0		29	10	S5803_170_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	170	0		29	10	S5803_170_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	170	0		29	10	S5803_170_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	170	0		29	10	S5803_170_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	171	0		29	10	S5803_171_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	171	0		29	10	S5803_171_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	171	0		29	10	S5803_171_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	171	0		29	10	S5803_171_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	210	0		29	10	S5803_210_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	210	0		29	10	S5803_210_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	210	0		29	10	S5803_210_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	45	45								45											45	Non-Preferred Brand																					
S5803	211	0		29	10	S5803_211_0	1	1	2	1	Generic	010000		2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	0.00	0.00								0.00											0.00
S5803	211	0		29	10	S5803_211_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	1	Preferred Brand	30	30								30											30	Preferred Brand																					
S5803	211	0		29	10	S5803_211_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																					
S5803	214	0		29	10	S5803_214_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	214	0		29	10	S5803_214_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	214	0		29	10	S5803_214_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	214	0		29	10	S5803_214_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	215	0		29	10	S5803_215_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	215	0		29	10	S5803_215_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	215	0		29	10	S5803_215_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	215	0		29	10	S5803_215_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	218	0		29	10	S5803_218_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	218	0		29	10	S5803_218_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	218	0		29	10	S5803_218_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	218	0		29	10	S5803_218_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	218	0		29	10	S5803_218_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	218	0		29	10	S5803_218_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	218	0		29	10	S5803_218_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	218	0		29	10	S5803_218_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	219	0		29	10	S5803_219_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	219	0		29	10	S5803_219_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	219	0		29	10	S5803_219_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	219	0		29	10	S5803_219_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	219	0		29	10	S5803_219_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	219	0		29	10	S5803_219_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	219	0		29	10	S5803_219_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	219	0		29	10	S5803_219_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	220	0		29	10	S5803_220_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	220	0		29	10	S5803_220_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	220	0		29	10	S5803_220_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	220	0		29	10	S5803_220_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	220	0		29	10	S5803_220_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	220	0		29	10	S5803_220_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	220	0		29	10	S5803_220_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	220	0		29	10	S5803_220_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	221	0		29	10	S5803_221_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	221	0		29	10	S5803_221_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	221	0		29	10	S5803_221_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	221	0		29	10	S5803_221_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	221	0		29	10	S5803_221_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	221	0		29	10	S5803_221_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	221	0		29	10	S5803_221_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	221	0		29	10	S5803_221_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	222	0		29	10	S5803_222_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	222	0		29	10	S5803_222_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	222	0		29	10	S5803_222_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	222	0		29	10	S5803_222_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	222	0		29	10	S5803_222_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	222	0		29	10	S5803_222_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	222	0		29	10	S5803_222_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	222	0		29	10	S5803_222_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	223	0		29	10	S5803_223_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	223	0		29	10	S5803_223_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	223	0		29	10	S5803_223_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	223	0		29	10	S5803_223_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	223	0		29	10	S5803_223_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	223	0		29	10	S5803_223_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	223	0		29	10	S5803_223_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	223	0		29	10	S5803_223_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	224	0		29	10	S5803_224_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	224	0		29	10	S5803_224_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	224	0		29	10	S5803_224_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	224	0		29	10	S5803_224_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	224	0		29	10	S5803_224_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	224	0		29	10	S5803_224_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	224	0		29	10	S5803_224_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	224	0		29	10	S5803_224_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	225	0		29	10	S5803_225_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	225	0		29	10	S5803_225_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	225	0		29	10	S5803_225_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	225	0		29	10	S5803_225_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	225	0		29	10	S5803_225_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	225	0		29	10	S5803_225_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	225	0		29	10	S5803_225_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	225	0		29	10	S5803_225_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	226	0		29	10	S5803_226_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	226	0		29	10	S5803_226_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	226	0		29	10	S5803_226_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	226	0		29	10	S5803_226_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	226	0		29	10	S5803_226_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	226	0		29	10	S5803_226_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	226	0		29	10	S5803_226_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	226	0		29	10	S5803_226_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	227	0		29	10	S5803_227_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	227	0		29	10	S5803_227_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	227	0		29	10	S5803_227_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	227	0		29	10	S5803_227_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	227	0		29	10	S5803_227_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	227	0		29	10	S5803_227_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	227	0		29	10	S5803_227_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	227	0		29	10	S5803_227_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	228	0		29	10	S5803_228_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	228	0		29	10	S5803_228_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	228	0		29	10	S5803_228_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	228	0		29	10	S5803_228_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	228	0		29	10	S5803_228_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	228	0		29	10	S5803_228_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	228	0		29	10	S5803_228_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	228	0		29	10	S5803_228_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	229	0		29	10	S5803_229_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	229	0		29	10	S5803_229_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	229	0		29	10	S5803_229_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	229	0		29	10	S5803_229_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	229	0		29	10	S5803_229_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	229	0		29	10	S5803_229_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	229	0		29	10	S5803_229_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	229	0		29	10	S5803_229_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	230	0		29	10	S5803_230_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	230	0		29	10	S5803_230_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	230	0		29	10	S5803_230_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	230	0		29	10	S5803_230_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	230	0		29	10	S5803_230_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	230	0		29	10	S5803_230_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	230	0		29	10	S5803_230_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	230	0		29	10	S5803_230_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	231	0		29	10	S5803_231_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	231	0		29	10	S5803_231_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	231	0		29	10	S5803_231_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	231	0		29	10	S5803_231_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	231	0		29	10	S5803_231_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	231	0		29	10	S5803_231_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	231	0		29	10	S5803_231_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	231	0		29	10	S5803_231_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	232	0		29	10	S5803_232_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	232	0		29	10	S5803_232_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	232	0		29	10	S5803_232_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	232	0		29	10	S5803_232_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	232	0		29	10	S5803_232_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	232	0		29	10	S5803_232_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	232	0		29	10	S5803_232_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	232	0		29	10	S5803_232_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	233	0		29	10	S5803_233_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	233	0		29	10	S5803_233_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	233	0		29	10	S5803_233_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	233	0		29	10	S5803_233_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	233	0		29	10	S5803_233_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	233	0		29	10	S5803_233_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	233	0		29	10	S5803_233_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	233	0		29	10	S5803_233_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	234	0		29	10	S5803_234_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	234	0		29	10	S5803_234_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	234	0		29	10	S5803_234_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	234	0		29	10	S5803_234_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	234	0		29	10	S5803_234_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	234	0		29	10	S5803_234_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	234	0		29	10	S5803_234_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	234	0		29	10	S5803_234_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	235	0		29	10	S5803_235_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	235	0		29	10	S5803_235_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	235	0		29	10	S5803_235_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	235	0		29	10	S5803_235_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	235	0		29	10	S5803_235_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	235	0		29	10	S5803_235_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	235	0		29	10	S5803_235_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	235	0		29	10	S5803_235_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	236	0		29	10	S5803_236_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	236	0		29	10	S5803_236_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	236	0		29	10	S5803_236_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	236	0		29	10	S5803_236_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	236	0		29	10	S5803_236_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	236	0		29	10	S5803_236_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	236	0		29	10	S5803_236_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	236	0		29	10	S5803_236_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	237	0		29	10	S5803_237_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	237	0		29	10	S5803_237_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	237	0		29	10	S5803_237_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	237	0		29	10	S5803_237_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	237	0		29	10	S5803_237_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	237	0		29	10	S5803_237_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	237	0		29	10	S5803_237_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	237	0		29	10	S5803_237_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	238	0		29	10	S5803_238_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	238	0		29	10	S5803_238_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	238	0		29	10	S5803_238_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	238	0		29	10	S5803_238_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	238	0		29	10	S5803_238_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	238	0		29	10	S5803_238_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	238	0		29	10	S5803_238_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	238	0		29	10	S5803_238_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	239	0		29	10	S5803_239_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	239	0		29	10	S5803_239_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	239	0		29	10	S5803_239_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	239	0		29	10	S5803_239_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	239	0		29	10	S5803_239_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	239	0		29	10	S5803_239_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	239	0		29	10	S5803_239_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	239	0		29	10	S5803_239_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	240	0		29	10	S5803_240_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	240	0		29	10	S5803_240_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	240	0		29	10	S5803_240_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	240	0		29	10	S5803_240_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	240	0		29	10	S5803_240_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	240	0		29	10	S5803_240_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	240	0		29	10	S5803_240_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	240	0		29	10	S5803_240_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	241	0		29	10	S5803_241_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	241	0		29	10	S5803_241_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	241	0		29	10	S5803_241_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	241	0		29	10	S5803_241_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	241	0		29	10	S5803_241_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	241	0		29	10	S5803_241_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	241	0		29	10	S5803_241_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	241	0		29	10	S5803_241_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	242	0		29	10	S5803_242_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	242	0		29	10	S5803_242_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	242	0		29	10	S5803_242_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	242	0		29	10	S5803_242_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	242	0		29	10	S5803_242_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	242	0		29	10	S5803_242_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	242	0		29	10	S5803_242_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	242	0		29	10	S5803_242_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	243	0		29	10	S5803_243_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	243	0		29	10	S5803_243_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	243	0		29	10	S5803_243_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	243	0		29	10	S5803_243_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	243	0		29	10	S5803_243_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	243	0		29	10	S5803_243_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	243	0		29	10	S5803_243_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	243	0		29	10	S5803_243_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	244	0		29	10	S5803_244_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	244	0		29	10	S5803_244_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	244	0		29	10	S5803_244_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	244	0		29	10	S5803_244_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	244	0		29	10	S5803_244_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	244	0		29	10	S5803_244_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	244	0		29	10	S5803_244_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	244	0		29	10	S5803_244_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	245	0		29	10	S5803_245_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	245	0		29	10	S5803_245_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	245	0		29	10	S5803_245_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	245	0		29	10	S5803_245_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	245	0		29	10	S5803_245_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	245	0		29	10	S5803_245_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	245	0		29	10	S5803_245_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	245	0		29	10	S5803_245_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	246	0		29	10	S5803_246_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	246	0		29	10	S5803_246_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	246	0		29	10	S5803_246_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	246	0		29	10	S5803_246_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	246	0		29	10	S5803_246_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	246	0		29	10	S5803_246_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	246	0		29	10	S5803_246_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	246	0		29	10	S5803_246_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	247	0		29	10	S5803_247_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	247	0		29	10	S5803_247_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	247	0		29	10	S5803_247_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	247	0		29	10	S5803_247_0	2	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	247	0		29	10	S5803_247_0	2	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	247	0		29	10	S5803_247_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	247	0		29	10	S5803_247_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	247	0		29	10	S5803_247_0	2	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	248	0		29	10	S5803_248_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	248	0		29	10	S5803_248_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	248	0		29	10	S5803_248_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	248	0		29	10	S5803_248_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	248	0		29	10	S5803_248_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	248	0		29	10	S5803_248_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	248	0		29	10	S5803_248_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	248	0		29	10	S5803_248_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	249	0		29	10	S5803_249_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	249	0		29	10	S5803_249_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	249	0		29	10	S5803_249_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	249	0		29	10	S5803_249_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	249	0		29	10	S5803_249_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	249	0		29	10	S5803_249_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	249	0		29	10	S5803_249_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	249	0		29	10	S5803_249_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	250	0		29	10	S5803_250_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	250	0		29	10	S5803_250_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	250	0		29	10	S5803_250_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	250	0		29	10	S5803_250_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	250	0		29	10	S5803_250_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	250	0		29	10	S5803_250_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	250	0		29	10	S5803_250_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	250	0		29	10	S5803_250_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	251	0		29	10	S5803_251_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	251	0		29	10	S5803_251_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	251	0		29	10	S5803_251_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	251	0		29	10	S5803_251_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	251	0		29	10	S5803_251_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	251	0		29	10	S5803_251_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	251	0		29	10	S5803_251_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	251	0		29	10	S5803_251_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	252	0		29	10	S5803_252_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	252	0		29	10	S5803_252_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	252	0		29	10	S5803_252_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	252	0		29	10	S5803_252_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	252	0		29	10	S5803_252_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	252	0		29	10	S5803_252_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	252	0		29	10	S5803_252_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	252	0		29	10	S5803_252_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	253	0		29	10	S5803_253_0	1	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5803	253	0		29	10	S5803_253_0	1	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5803	253	0		29	10	S5803_253_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5803	253	0		29	10	S5803_253_0	1	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5803	253	0		29	10	S5803_253_0	1	4	4	1	Specialty	000010	1	1				Specialty	111000000010000000000	30	90								30											34	Specialty	2	1	Specialty	33	33								33											33	Specialty																					
S5803	253	0		29	10	S5803_253_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00											60.00
S5803	253	0		29	10	S5803_253_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00											30.00
S5803	253	0		29	10	S5803_253_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											34	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5805	001	0		29	10	S5805_001_0	3	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5805	001	0		29	10	S5805_001_0	3	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5805	001	0		29	10	S5805_001_0	3	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5805	001	0		29	10	S5805_001_0	3	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	80.75	242.25								80.75						227.25			242.25		80.75
S5810	035	0		29	10	S5810_035_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	035	0		29	10	S5810_035_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	035	0		29	10	S5810_035_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	035	0		29	10	S5810_035_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	035	0		29	10	S5810_035_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
S5810	036	0		29	10	S5810_036_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
S5810	036	0		29	10	S5810_036_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	036	0		29	10	S5810_036_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	036	0		29	10	S5810_036_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	036	0		29	10	S5810_036_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	037	0		29	10	S5810_037_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	037	0		29	10	S5810_037_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	037	0		29	10	S5810_037_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	037	0		29	10	S5810_037_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00
S5810	037	0		29	10	S5810_037_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	038	0		29	10	S5810_038_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					10.00			15.00		5.00
S5810	038	0		29	10	S5810_038_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				63.00	157.50		63.00	189.00			63.00					126.00			189.00		63.00
S5810	038	0		29	10	S5810_038_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
S5810	038	0		29	10	S5810_038_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
S5810	038	0		29	10	S5810_038_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				22.00	55.00		22.00	66.00			22.00					44.00			66.00		22.00
S5810	039	0		29	10	S5810_039_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
S5810	039	0		29	10	S5810_039_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	039	0		29	10	S5810_039_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				32.00	80.00		32.00	96.00			32.00					64.00			96.00		32.00
S5810	039	0		29	10	S5810_039_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				72.00	180.00		72.00	216.00			72.00					144.00			216.00		72.00
S5810	039	0		29	10	S5810_039_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
S5810	040	0		29	10	S5810_040_0	3	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					58.00			87.00		29.00
S5810	040	0		29	10	S5810_040_0	3	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					138.00			207.00		69.00
S5810	040	0		29	10	S5810_040_0	3	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00
S5810	040	0		29	10	S5810_040_0	3	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	040	0		29	10	S5810_040_0	3	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
S5810	041	0		29	10	S5810_041_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	14.00	42.00									14.00					28.00			42.00		14.00
S5810	041	0		29	10	S5810_041_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	041	0		29	10	S5810_041_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
S5810	041	0		29	10	S5810_041_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	041	0		29	10	S5810_041_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	042	0		29	10	S5810_042_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	042	0		29	10	S5810_042_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	14.00	42.00									14.00					28.00			42.00		14.00
S5810	042	0		29	10	S5810_042_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	042	0		29	10	S5810_042_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					50.00			75.00		25.00
S5810	042	0		29	10	S5810_042_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	043	0		29	10	S5810_043_0	3	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	043	0		29	10	S5810_043_0	3	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	043	0		29	10	S5810_043_0	3	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	043	0		29	10	S5810_043_0	3	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	043	0		29	10	S5810_043_0	3	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	044	0		29	10	S5810_044_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	66.00	198.00									66.00					132.00			198.00		66.00
S5810	044	0		29	10	S5810_044_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	044	0		29	10	S5810_044_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	14.00	42.00									14.00					28.00			42.00		14.00
S5810	044	0		29	10	S5810_044_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	044	0		29	10	S5810_044_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	045	0		29	10	S5810_045_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00
S5810	045	0		29	10	S5810_045_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	32.00	96.00									32.00					64.00			96.00		32.00
S5810	045	0		29	10	S5810_045_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	14.00	42.00									14.00					28.00			42.00		14.00
S5810	045	0		29	10	S5810_045_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	045	0		29	10	S5810_045_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	046	0		29	10	S5810_046_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	046	0		29	10	S5810_046_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	046	0		29	10	S5810_046_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					56.00			84.00		28.00
S5810	046	0		29	10	S5810_046_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
S5810	046	0		29	10	S5810_046_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	047	0		29	10	S5810_047_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	047	0		29	10	S5810_047_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	047	0		29	10	S5810_047_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	047	0		29	10	S5810_047_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	047	0		29	10	S5810_047_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	048	0		29	10	S5810_048_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	72.00	216.00									72.00					144.00			216.00		72.00
S5810	048	0		29	10	S5810_048_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	048	0		29	10	S5810_048_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	048	0		29	10	S5810_048_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	048	0		29	10	S5810_048_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	049	0		29	10	S5810_049_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					56.00			84.00		28.00
S5810	049	0		29	10	S5810_049_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					140.00			210.00		70.00
S5810	049	0		29	10	S5810_049_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	049	0		29	10	S5810_049_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	049	0		29	10	S5810_049_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	050	0		29	10	S5810_050_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	050	0		29	10	S5810_050_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	050	0		29	10	S5810_050_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	050	0		29	10	S5810_050_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	71.00	213.00									71.00					142.00			213.00		71.00
S5810	050	0		29	10	S5810_050_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	051	0		29	10	S5810_051_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	051	0		29	10	S5810_051_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	051	0		29	10	S5810_051_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					58.00			87.00		29.00
S5810	051	0		29	10	S5810_051_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	051	0		29	10	S5810_051_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					138.00			207.00		69.00
S5810	052	0		29	10	S5810_052_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	052	0		29	10	S5810_052_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	052	0		29	10	S5810_052_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	052	0		29	10	S5810_052_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	052	0		29	10	S5810_052_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	053	0		29	10	S5810_053_0	4	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	053	0		29	10	S5810_053_0	4	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	053	0		29	10	S5810_053_0	4	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	053	0		29	10	S5810_053_0	4	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	053	0		29	10	S5810_053_0	4	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	054	0		29	10	S5810_054_0	4	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	054	0		29	10	S5810_054_0	4	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	054	0		29	10	S5810_054_0	4	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	054	0		29	10	S5810_054_0	4	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	054	0		29	10	S5810_054_0	4	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	055	0		29	10	S5810_055_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	055	0		29	10	S5810_055_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	055	0		29	10	S5810_055_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	055	0		29	10	S5810_055_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	055	0		29	10	S5810_055_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	056	0		29	10	S5810_056_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	056	0		29	10	S5810_056_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				12.00	30.00		12.00	36.00			12.00					24.00			36.00		12.00
S5810	056	0		29	10	S5810_056_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00
S5810	056	0		29	10	S5810_056_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					136.00			204.00		68.00
S5810	056	0		29	10	S5810_056_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																					
S5810	057	0		29	10	S5810_057_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
S5810	057	0		29	10	S5810_057_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
S5810	057	0		29	10	S5810_057_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
S5810	057	0		29	10	S5810_057_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	057	0		29	10	S5810_057_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	058	0		29	10	S5810_058_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	058	0		29	10	S5810_058_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	058	0		29	10	S5810_058_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	058	0		29	10	S5810_058_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	058	0		29	10	S5810_058_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	059	0		29	10	S5810_059_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	059	0		29	10	S5810_059_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					4.00			6.00		2.00
S5810	059	0		29	10	S5810_059_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	22.00	66.00									22.00					44.00			66.00		22.00
S5810	059	0		29	10	S5810_059_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	059	0		29	10	S5810_059_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	62.00	186.00									62.00					124.00			186.00		62.00
S5810	060	0		29	10	S5810_060_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	060	0		29	10	S5810_060_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	060	0		29	10	S5810_060_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	060	0		29	10	S5810_060_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	060	0		29	10	S5810_060_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	061	0		29	10	S5810_061_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	061	0		29	10	S5810_061_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	061	0		29	10	S5810_061_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	061	0		29	10	S5810_061_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	061	0		29	10	S5810_061_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	062	0		29	10	S5810_062_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	062	0		29	10	S5810_062_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	13.00	39.00									13.00					26.00			39.00		13.00
S5810	062	0		29	10	S5810_062_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	062	0		29	10	S5810_062_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00
S5810	062	0		29	10	S5810_062_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	063	0		29	10	S5810_063_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	063	0		29	10	S5810_063_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	063	0		29	10	S5810_063_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	063	0		29	10	S5810_063_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	063	0		29	10	S5810_063_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	064	0		29	10	S5810_064_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	064	0		29	10	S5810_064_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00
S5810	064	0		29	10	S5810_064_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	064	0		29	10	S5810_064_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					54.00			81.00		27.00
S5810	064	0		29	10	S5810_064_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	065	0		29	10	S5810_065_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	065	0		29	10	S5810_065_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	065	0		29	10	S5810_065_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	065	0		29	10	S5810_065_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	065	0		29	10	S5810_065_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	066	0		29	10	S5810_066_0	3	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	066	0		29	10	S5810_066_0	3	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	066	0		29	10	S5810_066_0	3	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	066	0		29	10	S5810_066_0	3	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	066	0		29	10	S5810_066_0	3	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	067	0		29	10	S5810_067_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	067	0		29	10	S5810_067_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	067	0		29	10	S5810_067_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	067	0		29	10	S5810_067_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	067	0		29	10	S5810_067_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	068	0		29	10	S5810_068_0	2	1	3	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	068	0		29	10	S5810_068_0	2	2	3	1	Tier 2 - Non-Preferred Generic	000100		2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00									12.00					24.00			36.00		12.00
S5810	068	0		29	10	S5810_068_0	2	3	3	1	Tier 3 - Preferred Brand	000001		2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00
S5810	068	0		29	10	S5810_068_0	2	4	3	1	Tier 4 - Non-Preferred Brand	100000		2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					134.00			201.00		67.00
S5810	068	0		29	10	S5810_068_0	2	5	3	1	Tier 5 - Specialty	010010		1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																					
S5810	137	0		29	10	S5810_137_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	137	0		29	10	S5810_137_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	137	0		29	10	S5810_137_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	137	0		29	10	S5810_137_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	137	0		29	10	S5810_137_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	137	0		29	10	S5810_137_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	137	0		29	10	S5810_137_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	137	0		29	10	S5810_137_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	137	0		29	10	S5810_137_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	137	0		29	10	S5810_137_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	138	0		29	10	S5810_138_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	138	0		29	10	S5810_138_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	138	0		29	10	S5810_138_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	138	0		29	10	S5810_138_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00
S5810	138	0		29	10	S5810_138_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	138	0		29	10	S5810_138_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	138	0		29	10	S5810_138_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	138	0		29	10	S5810_138_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	138	0		29	10	S5810_138_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	138	0		29	10	S5810_138_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	139	0		29	10	S5810_139_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	139	0		29	10	S5810_139_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	139	0		29	10	S5810_139_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	139	0		29	10	S5810_139_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	139	0		29	10	S5810_139_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	139	0		29	10	S5810_139_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	139	0		29	10	S5810_139_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	139	0		29	10	S5810_139_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	139	0		29	10	S5810_139_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	139	0		29	10	S5810_139_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	140	0		29	10	S5810_140_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				36.00	90.00		36.00	108.00			36.00					72.00			108.00		36.00
S5810	140	0		29	10	S5810_140_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	140	0		29	10	S5810_140_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	140	0		29	10	S5810_140_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	140	0		29	10	S5810_140_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	140	0		29	10	S5810_140_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	140	0		29	10	S5810_140_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	140	0		29	10	S5810_140_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	140	0		29	10	S5810_140_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				76.00	190.00		76.00	228.00			76.00					152.00			228.00		76.00
S5810	140	0		29	10	S5810_140_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	141	0		29	10	S5810_141_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	141	0		29	10	S5810_141_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				36.00	90.00		36.00	108.00			36.00					72.00			108.00		36.00
S5810	141	0		29	10	S5810_141_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	141	0		29	10	S5810_141_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	141	0		29	10	S5810_141_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				77.00	192.50		77.00	231.00			77.00					154.00			231.00		77.00
S5810	141	0		29	10	S5810_141_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	141	0		29	10	S5810_141_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	141	0		29	10	S5810_141_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	141	0		29	10	S5810_141_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	141	0		29	10	S5810_141_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	142	0		29	10	S5810_142_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				40.00	100.00		40.00	120.00			40.00					80.00			120.00		40.00
S5810	142	0		29	10	S5810_142_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	142	0		29	10	S5810_142_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	142	0		29	10	S5810_142_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	142	0		29	10	S5810_142_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	142	0		29	10	S5810_142_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	142	0		29	10	S5810_142_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	142	0		29	10	S5810_142_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				86.00	215.00		86.00	258.00			86.00					172.00			258.00		86.00
S5810	142	0		29	10	S5810_142_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	142	0		29	10	S5810_142_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	143	0		29	10	S5810_143_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	143	0		29	10	S5810_143_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	143	0		29	10	S5810_143_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	143	0		29	10	S5810_143_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	143	0		29	10	S5810_143_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	143	0		29	10	S5810_143_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	143	0		29	10	S5810_143_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	143	0		29	10	S5810_143_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	143	0		29	10	S5810_143_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	143	0		29	10	S5810_143_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	144	0		29	10	S5810_144_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	144	0		29	10	S5810_144_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	144	0		29	10	S5810_144_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	144	0		29	10	S5810_144_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	144	0		29	10	S5810_144_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	144	0		29	10	S5810_144_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	144	0		29	10	S5810_144_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	144	0		29	10	S5810_144_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	144	0		29	10	S5810_144_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	144	0		29	10	S5810_144_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	145	0		29	10	S5810_145_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	145	0		29	10	S5810_145_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	145	0		29	10	S5810_145_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	145	0		29	10	S5810_145_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	145	0		29	10	S5810_145_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	145	0		29	10	S5810_145_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	145	0		29	10	S5810_145_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	145	0		29	10	S5810_145_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	145	0		29	10	S5810_145_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	145	0		29	10	S5810_145_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	146	0		29	10	S5810_146_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	146	0		29	10	S5810_146_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	146	0		29	10	S5810_146_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	146	0		29	10	S5810_146_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00
S5810	146	0		29	10	S5810_146_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	146	0		29	10	S5810_146_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	146	0		29	10	S5810_146_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	146	0		29	10	S5810_146_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	146	0		29	10	S5810_146_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	146	0		29	10	S5810_146_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	147	0		29	10	S5810_147_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	147	0		29	10	S5810_147_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	147	0		29	10	S5810_147_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	147	0		29	10	S5810_147_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	147	0		29	10	S5810_147_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	147	0		29	10	S5810_147_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	147	0		29	10	S5810_147_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	147	0		29	10	S5810_147_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	147	0		29	10	S5810_147_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	147	0		29	10	S5810_147_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	148	0		29	10	S5810_148_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00
S5810	148	0		29	10	S5810_148_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					74.00			111.00		37.00
S5810	148	0		29	10	S5810_148_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	148	0		29	10	S5810_148_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	148	0		29	10	S5810_148_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	148	0		29	10	S5810_148_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	148	0		29	10	S5810_148_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	148	0		29	10	S5810_148_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	148	0		29	10	S5810_148_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	148	0		29	10	S5810_148_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	149	0		29	10	S5810_149_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	149	0		29	10	S5810_149_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	149	0		29	10	S5810_149_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	149	0		29	10	S5810_149_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	149	0		29	10	S5810_149_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	149	0		29	10	S5810_149_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	149	0		29	10	S5810_149_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	149	0		29	10	S5810_149_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	149	0		29	10	S5810_149_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	149	0		29	10	S5810_149_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	150	0		29	10	S5810_150_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	150	0		29	10	S5810_150_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	150	0		29	10	S5810_150_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	150	0		29	10	S5810_150_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	150	0		29	10	S5810_150_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	150	0		29	10	S5810_150_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	150	0		29	10	S5810_150_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	150	0		29	10	S5810_150_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	150	0		29	10	S5810_150_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	150	0		29	10	S5810_150_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	151	0		29	10	S5810_151_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	151	0		29	10	S5810_151_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	151	0		29	10	S5810_151_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	151	0		29	10	S5810_151_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	151	0		29	10	S5810_151_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	151	0		29	10	S5810_151_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00
S5810	151	0		29	10	S5810_151_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	151	0		29	10	S5810_151_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	151	0		29	10	S5810_151_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	151	0		29	10	S5810_151_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00
S5810	152	0		29	10	S5810_152_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	152	0		29	10	S5810_152_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	152	0		29	10	S5810_152_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	152	0		29	10	S5810_152_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	152	0		29	10	S5810_152_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	152	0		29	10	S5810_152_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	152	0		29	10	S5810_152_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	152	0		29	10	S5810_152_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	152	0		29	10	S5810_152_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	152	0		29	10	S5810_152_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	153	0		29	10	S5810_153_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	153	0		29	10	S5810_153_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	153	0		29	10	S5810_153_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	153	0		29	10	S5810_153_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	153	0		29	10	S5810_153_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	153	0		29	10	S5810_153_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	153	0		29	10	S5810_153_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	153	0		29	10	S5810_153_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	153	0		29	10	S5810_153_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	153	0		29	10	S5810_153_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	154	0		29	10	S5810_154_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	154	0		29	10	S5810_154_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	154	0		29	10	S5810_154_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	154	0		29	10	S5810_154_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	154	0		29	10	S5810_154_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	154	0		29	10	S5810_154_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00
S5810	154	0		29	10	S5810_154_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	154	0		29	10	S5810_154_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	154	0		29	10	S5810_154_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	154	0		29	10	S5810_154_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	155	0		29	10	S5810_155_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	155	0		29	10	S5810_155_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	155	0		29	10	S5810_155_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	155	0		29	10	S5810_155_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	155	0		29	10	S5810_155_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	155	0		29	10	S5810_155_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	155	0		29	10	S5810_155_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	155	0		29	10	S5810_155_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	155	0		29	10	S5810_155_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	155	0		29	10	S5810_155_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	156	0		29	10	S5810_156_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	156	0		29	10	S5810_156_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	156	0		29	10	S5810_156_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	156	0		29	10	S5810_156_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00
S5810	156	0		29	10	S5810_156_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	156	0		29	10	S5810_156_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	156	0		29	10	S5810_156_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	156	0		29	10	S5810_156_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	156	0		29	10	S5810_156_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	156	0		29	10	S5810_156_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	157	0		29	10	S5810_157_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00
S5810	157	0		29	10	S5810_157_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	157	0		29	10	S5810_157_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	157	0		29	10	S5810_157_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	157	0		29	10	S5810_157_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	157	0		29	10	S5810_157_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	157	0		29	10	S5810_157_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	157	0		29	10	S5810_157_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	157	0		29	10	S5810_157_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	157	0		29	10	S5810_157_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	158	0		29	10	S5810_158_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				74.00	185.00		74.00	222.00			74.00					148.00			222.00		74.00
S5810	158	0		29	10	S5810_158_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		34.00	102.00			34.00					68.00			102.00		34.00
S5810	158	0		29	10	S5810_158_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	158	0		29	10	S5810_158_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	158	0		29	10	S5810_158_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	158	0		29	10	S5810_158_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	158	0		29	10	S5810_158_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	158	0		29	10	S5810_158_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	158	0		29	10	S5810_158_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	158	0		29	10	S5810_158_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	159	0		29	10	S5810_159_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	159	0		29	10	S5810_159_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	159	0		29	10	S5810_159_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	159	0		29	10	S5810_159_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	159	0		29	10	S5810_159_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	159	0		29	10	S5810_159_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	159	0		29	10	S5810_159_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	159	0		29	10	S5810_159_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	159	0		29	10	S5810_159_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	159	0		29	10	S5810_159_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	160	0		29	10	S5810_160_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	160	0		29	10	S5810_160_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	160	0		29	10	S5810_160_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	160	0		29	10	S5810_160_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	160	0		29	10	S5810_160_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	160	0		29	10	S5810_160_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	160	0		29	10	S5810_160_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	160	0		29	10	S5810_160_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	160	0		29	10	S5810_160_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	160	0		29	10	S5810_160_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	161	0		29	10	S5810_161_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00
S5810	161	0		29	10	S5810_161_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	161	0		29	10	S5810_161_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	161	0		29	10	S5810_161_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	161	0		29	10	S5810_161_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	161	0		29	10	S5810_161_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	161	0		29	10	S5810_161_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	161	0		29	10	S5810_161_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00
S5810	161	0		29	10	S5810_161_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	161	0		29	10	S5810_161_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	162	0		29	10	S5810_162_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	162	0		29	10	S5810_162_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	162	0		29	10	S5810_162_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	162	0		29	10	S5810_162_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	162	0		29	10	S5810_162_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	162	0		29	10	S5810_162_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	162	0		29	10	S5810_162_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	162	0		29	10	S5810_162_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	162	0		29	10	S5810_162_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	162	0		29	10	S5810_162_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	163	0		29	10	S5810_163_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	163	0		29	10	S5810_163_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	163	0		29	10	S5810_163_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	163	0		29	10	S5810_163_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	163	0		29	10	S5810_163_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	163	0		29	10	S5810_163_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	163	0		29	10	S5810_163_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	163	0		29	10	S5810_163_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	163	0		29	10	S5810_163_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	163	0		29	10	S5810_163_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	164	0		29	10	S5810_164_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	164	0		29	10	S5810_164_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	164	0		29	10	S5810_164_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	164	0		29	10	S5810_164_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	164	0		29	10	S5810_164_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	164	0		29	10	S5810_164_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	164	0		29	10	S5810_164_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	164	0		29	10	S5810_164_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	164	0		29	10	S5810_164_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	164	0		29	10	S5810_164_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	165	0		29	10	S5810_165_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	165	0		29	10	S5810_165_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	165	0		29	10	S5810_165_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	165	0		29	10	S5810_165_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	165	0		29	10	S5810_165_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	165	0		29	10	S5810_165_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	165	0		29	10	S5810_165_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	165	0		29	10	S5810_165_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	165	0		29	10	S5810_165_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	165	0		29	10	S5810_165_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	166	0		29	10	S5810_166_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	166	0		29	10	S5810_166_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	166	0		29	10	S5810_166_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	166	0		29	10	S5810_166_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	166	0		29	10	S5810_166_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	166	0		29	10	S5810_166_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	166	0		29	10	S5810_166_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	166	0		29	10	S5810_166_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	166	0		29	10	S5810_166_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	166	0		29	10	S5810_166_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	167	0		29	10	S5810_167_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	167	0		29	10	S5810_167_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	167	0		29	10	S5810_167_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	167	0		29	10	S5810_167_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	167	0		29	10	S5810_167_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	167	0		29	10	S5810_167_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	167	0		29	10	S5810_167_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	167	0		29	10	S5810_167_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	167	0		29	10	S5810_167_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	167	0		29	10	S5810_167_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	168	0		29	10	S5810_168_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	168	0		29	10	S5810_168_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	168	0		29	10	S5810_168_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	168	0		29	10	S5810_168_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	168	0		29	10	S5810_168_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	168	0		29	10	S5810_168_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	168	0		29	10	S5810_168_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	168	0		29	10	S5810_168_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	168	0		29	10	S5810_168_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	168	0		29	10	S5810_168_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	169	0		29	10	S5810_169_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	169	0		29	10	S5810_169_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	169	0		29	10	S5810_169_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	169	0		29	10	S5810_169_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	169	0		29	10	S5810_169_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	169	0		29	10	S5810_169_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	169	0		29	10	S5810_169_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	169	0		29	10	S5810_169_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	169	0		29	10	S5810_169_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	169	0		29	10	S5810_169_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	170	0		29	10	S5810_170_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	170	0		29	10	S5810_170_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	170	0		29	10	S5810_170_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		40.00	120.00			40.00					80.00			120.00		40.00
S5810	170	0		29	10	S5810_170_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				90.00	225.00		90.00	270.00			90.00					180.00			270.00		90.00
S5810	170	0		29	10	S5810_170_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	170	0		29	10	S5810_170_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		10.00	30.00			10.00					20.00			30.00		10.00
S5810	170	0		29	10	S5810_170_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	2			Tier 2 - Non-Preferred Generic																							Tier 2 - Non-Preferred Generic			Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																					
S5810	170	0		29	10	S5810_170_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	170	0		29	10	S5810_170_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	170	0		29	10	S5810_170_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	171	0		29	10	S5810_171_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	171	0		29	10	S5810_171_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	171	0		29	10	S5810_171_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	171	0		29	10	S5810_171_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	171	0		29	10	S5810_171_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	171	0		29	10	S5810_171_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	171	0		29	10	S5810_171_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	171	0		29	10	S5810_171_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	171	0		29	10	S5810_171_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	171	0		29	10	S5810_171_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	172	0		29	10	S5810_172_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	172	0		29	10	S5810_172_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	172	0		29	10	S5810_172_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	172	0		29	10	S5810_172_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	172	0		29	10	S5810_172_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	172	0		29	10	S5810_172_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	172	0		29	10	S5810_172_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	172	0		29	10	S5810_172_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	172	0		29	10	S5810_172_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	172	0		29	10	S5810_172_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	173	0		29	10	S5810_173_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	173	0		29	10	S5810_173_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	173	0		29	10	S5810_173_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	173	0		29	10	S5810_173_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	173	0		29	10	S5810_173_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	173	0		29	10	S5810_173_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	173	0		29	10	S5810_173_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	173	0		29	10	S5810_173_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	173	0		29	10	S5810_173_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	173	0		29	10	S5810_173_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	174	0		29	10	S5810_174_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
S5810	174	0		29	10	S5810_174_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	174	0		29	10	S5810_174_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	174	0		29	10	S5810_174_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	174	0		29	10	S5810_174_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	174	0		29	10	S5810_174_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	174	0		29	10	S5810_174_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
S5810	174	0		29	10	S5810_174_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				65.00	162.50		65.00	195.00			65.00					130.00			195.00		65.00
S5810	174	0		29	10	S5810_174_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	174	0		29	10	S5810_174_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	175	0		29	10	S5810_175_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	175	0		29	10	S5810_175_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	175	0		29	10	S5810_175_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				65.00	162.50		65.00	195.00			65.00					130.00			195.00		65.00
S5810	175	0		29	10	S5810_175_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
S5810	175	0		29	10	S5810_175_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	175	0		29	10	S5810_175_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	175	0		29	10	S5810_175_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	175	0		29	10	S5810_175_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	175	0		29	10	S5810_175_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	175	0		29	10	S5810_175_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
S5810	176	0		29	10	S5810_176_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	176	0		29	10	S5810_176_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	176	0		29	10	S5810_176_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
S5810	176	0		29	10	S5810_176_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				65.00	162.50		65.00	195.00			65.00					130.00			195.00		65.00
S5810	176	0		29	10	S5810_176_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	176	0		29	10	S5810_176_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	176	0		29	10	S5810_176_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	176	0		29	10	S5810_176_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
S5810	176	0		29	10	S5810_176_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	176	0		29	10	S5810_176_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	177	0		29	10	S5810_177_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	177	0		29	10	S5810_177_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	177	0		29	10	S5810_177_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	177	0		29	10	S5810_177_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	177	0		29	10	S5810_177_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	177	0		29	10	S5810_177_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	177	0		29	10	S5810_177_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	177	0		29	10	S5810_177_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	177	0		29	10	S5810_177_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	177	0		29	10	S5810_177_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	178	0		29	10	S5810_178_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	178	0		29	10	S5810_178_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	178	0		29	10	S5810_178_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	178	0		29	10	S5810_178_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	178	0		29	10	S5810_178_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	178	0		29	10	S5810_178_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	178	0		29	10	S5810_178_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	178	0		29	10	S5810_178_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	178	0		29	10	S5810_178_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	178	0		29	10	S5810_178_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	179	0		29	10	S5810_179_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	179	0		29	10	S5810_179_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	179	0		29	10	S5810_179_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	179	0		29	10	S5810_179_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	179	0		29	10	S5810_179_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	179	0		29	10	S5810_179_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	179	0		29	10	S5810_179_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	179	0		29	10	S5810_179_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	179	0		29	10	S5810_179_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	179	0		29	10	S5810_179_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	180	0		29	10	S5810_180_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	180	0		29	10	S5810_180_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	180	0		29	10	S5810_180_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	180	0		29	10	S5810_180_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	180	0		29	10	S5810_180_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	180	0		29	10	S5810_180_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	180	0		29	10	S5810_180_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	180	0		29	10	S5810_180_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	180	0		29	10	S5810_180_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	180	0		29	10	S5810_180_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	181	0		29	10	S5810_181_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	181	0		29	10	S5810_181_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	181	0		29	10	S5810_181_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	181	0		29	10	S5810_181_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	181	0		29	10	S5810_181_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	181	0		29	10	S5810_181_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	181	0		29	10	S5810_181_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	181	0		29	10	S5810_181_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	181	0		29	10	S5810_181_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	181	0		29	10	S5810_181_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	182	0		29	10	S5810_182_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	182	0		29	10	S5810_182_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	182	0		29	10	S5810_182_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	182	0		29	10	S5810_182_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	182	0		29	10	S5810_182_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	182	0		29	10	S5810_182_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	182	0		29	10	S5810_182_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	182	0		29	10	S5810_182_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	182	0		29	10	S5810_182_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	182	0		29	10	S5810_182_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	183	0		29	10	S5810_183_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	183	0		29	10	S5810_183_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	183	0		29	10	S5810_183_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	183	0		29	10	S5810_183_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	183	0		29	10	S5810_183_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	183	0		29	10	S5810_183_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	183	0		29	10	S5810_183_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	183	0		29	10	S5810_183_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	183	0		29	10	S5810_183_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	183	0		29	10	S5810_183_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	184	0		29	10	S5810_184_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	184	0		29	10	S5810_184_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	184	0		29	10	S5810_184_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	184	0		29	10	S5810_184_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	184	0		29	10	S5810_184_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	184	0		29	10	S5810_184_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	184	0		29	10	S5810_184_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	184	0		29	10	S5810_184_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	184	0		29	10	S5810_184_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	184	0		29	10	S5810_184_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	185	0		29	10	S5810_185_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	185	0		29	10	S5810_185_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	185	0		29	10	S5810_185_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	185	0		29	10	S5810_185_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	185	0		29	10	S5810_185_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	185	0		29	10	S5810_185_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	185	0		29	10	S5810_185_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	185	0		29	10	S5810_185_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	185	0		29	10	S5810_185_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	185	0		29	10	S5810_185_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	186	0		29	10	S5810_186_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	186	0		29	10	S5810_186_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	186	0		29	10	S5810_186_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	186	0		29	10	S5810_186_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	186	0		29	10	S5810_186_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	186	0		29	10	S5810_186_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	186	0		29	10	S5810_186_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	186	0		29	10	S5810_186_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	186	0		29	10	S5810_186_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	186	0		29	10	S5810_186_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	187	0		29	10	S5810_187_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	187	0		29	10	S5810_187_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	187	0		29	10	S5810_187_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	187	0		29	10	S5810_187_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	187	0		29	10	S5810_187_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	187	0		29	10	S5810_187_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	187	0		29	10	S5810_187_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	187	0		29	10	S5810_187_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	187	0		29	10	S5810_187_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	187	0		29	10	S5810_187_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	188	0		29	10	S5810_188_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	188	0		29	10	S5810_188_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	188	0		29	10	S5810_188_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	188	0		29	10	S5810_188_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	188	0		29	10	S5810_188_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	188	0		29	10	S5810_188_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	188	0		29	10	S5810_188_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	188	0		29	10	S5810_188_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	188	0		29	10	S5810_188_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	188	0		29	10	S5810_188_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	189	0		29	10	S5810_189_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	189	0		29	10	S5810_189_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	189	0		29	10	S5810_189_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	189	0		29	10	S5810_189_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	189	0		29	10	S5810_189_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	189	0		29	10	S5810_189_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	189	0		29	10	S5810_189_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	189	0		29	10	S5810_189_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	189	0		29	10	S5810_189_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	189	0		29	10	S5810_189_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	190	0		29	10	S5810_190_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	190	0		29	10	S5810_190_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	190	0		29	10	S5810_190_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	190	0		29	10	S5810_190_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	190	0		29	10	S5810_190_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	190	0		29	10	S5810_190_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	190	0		29	10	S5810_190_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	190	0		29	10	S5810_190_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	190	0		29	10	S5810_190_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	190	0		29	10	S5810_190_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	191	0		29	10	S5810_191_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	191	0		29	10	S5810_191_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	191	0		29	10	S5810_191_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	191	0		29	10	S5810_191_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	191	0		29	10	S5810_191_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	191	0		29	10	S5810_191_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	191	0		29	10	S5810_191_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	191	0		29	10	S5810_191_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	191	0		29	10	S5810_191_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	191	0		29	10	S5810_191_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	192	0		29	10	S5810_192_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	192	0		29	10	S5810_192_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	192	0		29	10	S5810_192_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					50.00			75.00		25.00
S5810	192	0		29	10	S5810_192_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	192	0		29	10	S5810_192_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	100011011001000010010				31	90		31	90			10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																					
S5810	192	0		29	10	S5810_192_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				65.00	162.50		65.00	195.00			65.00					130.00			195.00		65.00
S5810	192	0		29	10	S5810_192_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00
S5810	192	0		29	10	S5810_192_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				10.00	25.00		10.00	30.00			10.00					20.00			30.00		10.00
S5810	192	0		29	10	S5810_192_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				0.00	0.00		0.00	0.00			0.00					0.00			0.00		0.00
S5810	192	0		29	10	S5810_192_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	193	0		29	10	S5810_193_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	193	0		29	10	S5810_193_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	193	0		29	10	S5810_193_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	193	0		29	10	S5810_193_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	193	0		29	10	S5810_193_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	193	0		29	10	S5810_193_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	193	0		29	10	S5810_193_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	193	0		29	10	S5810_193_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	193	0		29	10	S5810_193_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	193	0		29	10	S5810_193_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	194	0		29	10	S5810_194_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	194	0		29	10	S5810_194_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	194	0		29	10	S5810_194_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	194	0		29	10	S5810_194_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	194	0		29	10	S5810_194_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	194	0		29	10	S5810_194_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	194	0		29	10	S5810_194_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	194	0		29	10	S5810_194_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	194	0		29	10	S5810_194_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	194	0		29	10	S5810_194_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	195	0		29	10	S5810_195_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	195	0		29	10	S5810_195_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	195	0		29	10	S5810_195_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	195	0		29	10	S5810_195_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	195	0		29	10	S5810_195_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	195	0		29	10	S5810_195_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	195	0		29	10	S5810_195_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	195	0		29	10	S5810_195_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	195	0		29	10	S5810_195_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	195	0		29	10	S5810_195_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	196	0		29	10	S5810_196_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	196	0		29	10	S5810_196_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	196	0		29	10	S5810_196_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	196	0		29	10	S5810_196_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	196	0		29	10	S5810_196_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	196	0		29	10	S5810_196_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	196	0		29	10	S5810_196_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	196	0		29	10	S5810_196_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	196	0		29	10	S5810_196_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	196	0		29	10	S5810_196_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	197	0		29	10	S5810_197_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	197	0		29	10	S5810_197_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	197	0		29	10	S5810_197_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	197	0		29	10	S5810_197_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	197	0		29	10	S5810_197_0	3	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	197	0		29	10	S5810_197_0	3	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	197	0		29	10	S5810_197_0	3	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	197	0		29	10	S5810_197_0	3	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	197	0		29	10	S5810_197_0	3	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	197	0		29	10	S5810_197_0	3	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	198	0		29	10	S5810_198_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	198	0		29	10	S5810_198_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	198	0		29	10	S5810_198_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	198	0		29	10	S5810_198_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	198	0		29	10	S5810_198_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	198	0		29	10	S5810_198_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	198	0		29	10	S5810_198_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	198	0		29	10	S5810_198_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	198	0		29	10	S5810_198_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	198	0		29	10	S5810_198_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	199	0		29	10	S5810_199_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	199	0		29	10	S5810_199_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	199	0		29	10	S5810_199_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	199	0		29	10	S5810_199_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	199	0		29	10	S5810_199_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	199	0		29	10	S5810_199_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	199	0		29	10	S5810_199_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	199	0		29	10	S5810_199_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	199	0		29	10	S5810_199_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	199	0		29	10	S5810_199_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	200	0		29	10	S5810_200_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	200	0		29	10	S5810_200_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	200	0		29	10	S5810_200_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	200	0		29	10	S5810_200_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	200	0		29	10	S5810_200_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	200	0		29	10	S5810_200_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	200	0		29	10	S5810_200_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	200	0		29	10	S5810_200_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	200	0		29	10	S5810_200_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	200	0		29	10	S5810_200_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	201	0		29	10	S5810_201_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	201	0		29	10	S5810_201_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	201	0		29	10	S5810_201_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	201	0		29	10	S5810_201_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	201	0		29	10	S5810_201_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	201	0		29	10	S5810_201_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	201	0		29	10	S5810_201_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	201	0		29	10	S5810_201_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	201	0		29	10	S5810_201_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	201	0		29	10	S5810_201_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	202	0		29	10	S5810_202_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	202	0		29	10	S5810_202_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	202	0		29	10	S5810_202_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	202	0		29	10	S5810_202_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	202	0		29	10	S5810_202_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	202	0		29	10	S5810_202_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	202	0		29	10	S5810_202_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	202	0		29	10	S5810_202_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	202	0		29	10	S5810_202_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	202	0		29	10	S5810_202_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	203	0		29	10	S5810_203_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	203	0		29	10	S5810_203_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	203	0		29	10	S5810_203_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	203	0		29	10	S5810_203_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	203	0		29	10	S5810_203_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	203	0		29	10	S5810_203_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	203	0		29	10	S5810_203_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	203	0		29	10	S5810_203_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	203	0		29	10	S5810_203_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	203	0		29	10	S5810_203_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	204	0		29	10	S5810_204_0	2	1	4	3	Tier 1 - Preferred Generic	001000	3	2	1		1	Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5810	204	0		29	10	S5810_204_0	2	5	4	1	Tier 5 - Specialty	010010	1	1				Tier 5 - Specialty	111000000001000010010	31	90									10				90			90			31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																					
S5810	204	0		29	10	S5810_204_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2				Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 4 - Non-Preferred Brand	2	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00									65.00					130.00			195.00		65.00
S5810	204	0		29	10	S5810_204_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2				Tier 3 - Preferred Brand	111000000001000010010	31	90									10				90			90			31	Tier 3 - Preferred Brand	2	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00
S5810	204	0		29	10	S5810_204_0	2	5	4	3	Tier 5 - Specialty	010010	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S5810	204	0		29	10	S5810_204_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2				Tier 1 - Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00									0.00					0.00			0.00		0.00
S5810	204	0		29	10	S5810_204_0	2	2	4	3	Tier 2 - Non-Preferred Generic	000100	3	2	1		1	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00
S5810	204	0		29	10	S5810_204_0	2	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2			Tier 3 - Preferred Brand																							Tier 3 - Preferred Brand			Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand																					
S5810	204	0		29	10	S5810_204_0	2	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	2			Tier 4 - Non-Preferred Brand																							Tier 4 - Non-Preferred Brand			Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																					
S5810	204	0		29	10	S5810_204_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2				Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10				90			90			31	Tier 2 - Non-Preferred Generic	2	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00
S5820	001	0		29	10	S5820_001_0	3	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5820	001	0		29	10	S5820_001_0	3	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	001	0		29	10	S5820_001_0	3	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	001	0		29	10	S5820_001_0	3	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	002	0		29	10	S5820_002_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	94.20	282.60								94.20						267.60			282.60		94.20
S5820	002	0		29	10	S5820_002_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	002	0		29	10	S5820_002_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	002	0		29	10	S5820_002_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	003	0		29	10	S5820_003_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	003	0		29	10	S5820_003_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	003	0		29	10	S5820_003_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	75.10	225.30								75.10						210.30			225.30		75.10
S5820	003	0		29	10	S5820_003_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	004	0		29	10	S5820_004_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	004	0		29	10	S5820_004_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	004	0		29	10	S5820_004_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	79.95	239.85								79.95						224.85			239.85		79.95
S5820	004	0		29	10	S5820_004_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	005	0		29	10	S5820_005_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	005	0		29	10	S5820_005_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	005	0		29	10	S5820_005_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	005	0		29	10	S5820_005_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	91.50	274.50								91.50						259.50			274.50		91.50
S5820	006	0		29	10	S5820_006_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	006	0		29	10	S5820_006_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	006	0		29	10	S5820_006_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	80.30	240.90								80.30						225.90			240.90		80.30
S5820	006	0		29	10	S5820_006_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	007	0		29	10	S5820_007_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	007	0		29	10	S5820_007_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	007	0		29	10	S5820_007_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	007	0		29	10	S5820_007_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	76.50	229.50								76.50						214.50			229.50		76.50
S5820	008	0		29	10	S5820_008_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	008	0		29	10	S5820_008_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	79.65	238.95								79.65						223.95			238.95		79.65
S5820	008	0		29	10	S5820_008_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	008	0		29	10	S5820_008_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	009	0		29	10	S5820_009_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	009	0		29	10	S5820_009_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	009	0		29	10	S5820_009_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	74.05	222.15								74.05						207.15			222.15		74.05
S5820	009	0		29	10	S5820_009_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	010	0		29	10	S5820_010_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	010	0		29	10	S5820_010_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	010	0		29	10	S5820_010_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	74.80	224.40								74.80						209.40			224.40		74.80
S5820	010	0		29	10	S5820_010_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	011	0		29	10	S5820_011_0	3	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	70.10	210.30								70.10						195.30			210.30		70.10
S5820	011	0		29	10	S5820_011_0	3	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	011	0		29	10	S5820_011_0	3	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	011	0		29	10	S5820_011_0	3	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	012	0		29	10	S5820_012_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	012	0		29	10	S5820_012_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	012	0		29	10	S5820_012_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	94.10	282.30								94.10						267.30			282.30		94.10
S5820	012	0		29	10	S5820_012_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	013	0		29	10	S5820_013_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	013	0		29	10	S5820_013_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	013	0		29	10	S5820_013_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	84.10	252.30								84.10						237.30			252.30		84.10
S5820	013	0		29	10	S5820_013_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	014	0		29	10	S5820_014_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	76.00	228.00								76.00						213.00			228.00		76.00
S5820	014	0		29	10	S5820_014_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	014	0		29	10	S5820_014_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	014	0		29	10	S5820_014_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	015	0		29	10	S5820_015_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	015	0		29	10	S5820_015_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	015	0		29	10	S5820_015_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	97.75	293.25								97.75						278.25			293.25		97.75
S5820	015	0		29	10	S5820_015_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	016	0		29	10	S5820_016_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	016	0		29	10	S5820_016_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	016	0		29	10	S5820_016_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	80.40	241.20								80.40						226.20			241.20		80.40
S5820	016	0		29	10	S5820_016_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	017	0		29	10	S5820_017_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	017	0		29	10	S5820_017_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	017	0		29	10	S5820_017_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	017	0		29	10	S5820_017_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	83.00	249.00								83.00						234.00			249.00		83.00
S5820	018	0		29	10	S5820_018_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	018	0		29	10	S5820_018_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	018	0		29	10	S5820_018_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	75.85	227.55								75.85						212.55			227.55		75.85
S5820	018	0		29	10	S5820_018_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	019	0		29	10	S5820_019_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	019	0		29	10	S5820_019_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	70.60	211.80								70.60						196.80			211.80		70.60
S5820	019	0		29	10	S5820_019_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	019	0		29	10	S5820_019_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	020	0		29	10	S5820_020_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	66.25	198.75								66.25						183.75			198.75		66.25
S5820	020	0		29	10	S5820_020_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	020	0		29	10	S5820_020_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	020	0		29	10	S5820_020_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	021	0		29	10	S5820_021_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	73.30	219.90								73.30						204.90			219.90		73.30
S5820	021	0		29	10	S5820_021_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	021	0		29	10	S5820_021_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	021	0		29	10	S5820_021_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	022	0		29	10	S5820_022_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	022	0		29	10	S5820_022_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	022	0		29	10	S5820_022_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	74.55	223.65								74.55						208.65			223.65		74.55
S5820	022	0		29	10	S5820_022_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	023	0		29	10	S5820_023_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	023	0		29	10	S5820_023_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	74.75	224.25								74.75						209.25			224.25		74.75
S5820	023	0		29	10	S5820_023_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	023	0		29	10	S5820_023_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	024	0		29	10	S5820_024_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	024	0		29	10	S5820_024_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	76.20	228.60								76.20						213.60			228.60		76.20
S5820	024	0		29	10	S5820_024_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	024	0		29	10	S5820_024_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	025	0		29	10	S5820_025_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	84.30	252.90								84.30						237.90			252.90		84.30
S5820	025	0		29	10	S5820_025_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	025	0		29	10	S5820_025_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	025	0		29	10	S5820_025_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	026	0		29	10	S5820_026_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	026	0		29	10	S5820_026_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	026	0		29	10	S5820_026_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	88.80	266.40								88.80						251.40			266.40		88.80
S5820	026	0		29	10	S5820_026_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	027	0		29	10	S5820_027_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	84.70	254.10								84.70						239.10			254.10		84.70
S5820	027	0		29	10	S5820_027_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	027	0		29	10	S5820_027_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	027	0		29	10	S5820_027_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	028	0		29	10	S5820_028_0	3	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	028	0		29	10	S5820_028_0	3	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	028	0		29	10	S5820_028_0	3	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	86.30	258.90								86.30						243.90			258.90		86.30
S5820	028	0		29	10	S5820_028_0	3	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	029	0		29	10	S5820_029_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	029	0		29	10	S5820_029_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	029	0		29	10	S5820_029_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	029	0		29	10	S5820_029_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	81.20	243.60								81.20						228.60			243.60		81.20
S5820	030	0		29	10	S5820_030_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	030	0		29	10	S5820_030_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	76.85	230.55								76.85						215.55			230.55		76.85
S5820	030	0		29	10	S5820_030_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	030	0		29	10	S5820_030_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	031	0		29	10	S5820_031_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	031	0		29	10	S5820_031_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	031	0		29	10	S5820_031_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	031	0		29	10	S5820_031_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	84.65	253.95								84.65						238.95			253.95		84.65
S5820	032	0		29	10	S5820_032_0	3	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5820	032	0		29	10	S5820_032_0	3	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	032	0		29	10	S5820_032_0	3	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	032	0		29	10	S5820_032_0	3	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	033	0		29	10	S5820_033_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	033	0		29	10	S5820_033_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	033	0		29	10	S5820_033_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	74.00	222.00								74.00						207.00			222.00		74.00
S5820	033	0		29	10	S5820_033_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	034	0		29	10	S5820_034_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	89.25	267.75								89.25						252.75			267.75		89.25
S5820	034	0		29	10	S5820_034_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	034	0		29	10	S5820_034_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	034	0		29	10	S5820_034_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	035	0		29	10	S5820_035_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	035	0		29	10	S5820_035_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	035	0		29	10	S5820_035_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	84.30	252.90								84.30						237.90			252.90		84.30
S5820	035	0		29	10	S5820_035_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	036	0		29	10	S5820_036_0	2	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	036	0		29	10	S5820_036_0	2	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	036	0		29	10	S5820_036_0	2	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	036	0		29	10	S5820_036_0	2	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	89.35	268.05								89.35						253.05			268.05		89.35
S5820	037	0		29	10	S5820_037_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	037	0		29	10	S5820_037_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	037	0		29	10	S5820_037_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	64.45	193.35								64.45						178.35			193.35		64.45
S5820	037	0		29	10	S5820_037_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	038	0		29	10	S5820_038_0	4	1	3	1	Tier 1-Preferred Generic	001000		2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	038	0		29	10	S5820_038_0	4	2	3	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	38.00	114.00								38.00						99.00			114.00		38.00
S5820	038	0		29	10	S5820_038_0	4	3	3	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	86.75	260.25								86.75						245.25			260.25		86.75
S5820	038	0		29	10	S5820_038_0	4	4	3	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	142	0		29	10	S5820_142_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	142	0		29	10	S5820_142_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5820	142	0		29	10	S5820_142_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5820	142	0		29	10	S5820_142_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	142	0		29	10	S5820_142_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5820	142	0		29	10	S5820_142_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5820	142	0		29	10	S5820_142_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5820	142	0		29	10	S5820_142_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5820	143	0		29	10	S5820_143_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5820	143	0		29	10	S5820_143_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5820	143	0		29	10	S5820_143_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5820	143	0		29	10	S5820_143_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5820	143	0		29	10	S5820_143_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	143	0		29	10	S5820_143_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	143	0		29	10	S5820_143_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5820	143	0		29	10	S5820_143_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5820	144	0		29	10	S5820_144_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5820	144	0		29	10	S5820_144_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5820	144	0		29	10	S5820_144_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5820	144	0		29	10	S5820_144_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5820	144	0		29	10	S5820_144_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	144	0		29	10	S5820_144_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5820	144	0		29	10	S5820_144_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5820	144	0		29	10	S5820_144_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	145	0		29	10	S5820_145_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5820	145	0		29	10	S5820_145_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5820	145	0		29	10	S5820_145_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5820	145	0		29	10	S5820_145_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5820	145	0		29	10	S5820_145_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	145	0		29	10	S5820_145_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	145	0		29	10	S5820_145_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5820	145	0		29	10	S5820_145_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5820	146	0		29	10	S5820_146_0	3	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5820	146	0		29	10	S5820_146_0	3	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5820	146	0		29	10	S5820_146_0	3	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5820	146	0		29	10	S5820_146_0	3	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5820	146	0		29	10	S5820_146_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5820	146	0		29	10	S5820_146_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5820	146	0		29	10	S5820_146_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5820	146	0		29	10	S5820_146_0	3	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5820	147	0		29	10	S5820_147_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5820	147	0		29	10	S5820_147_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5820	147	0		29	10	S5820_147_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5820	147	0		29	10	S5820_147_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	59.90	179.70								59.90						164.70			179.70		59.90
S5820	148	0		29	10	S5820_148_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5820	148	0		29	10	S5820_148_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5820	148	0		29	10	S5820_148_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	58.90	176.70								58.90						161.70			176.70		58.90
S5820	148	0		29	10	S5820_148_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5820	149	0		29	10	S5820_149_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5820	149	0		29	10	S5820_149_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5820	149	0		29	10	S5820_149_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5820	149	0		29	10	S5820_149_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	59.90	179.70								59.90						164.70			179.70		59.90
S5820	150	0		29	10	S5820_150_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5820	150	0		29	10	S5820_150_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	59.55	178.65								59.55						163.65			178.65		59.55
S5820	150	0		29	10	S5820_150_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5820	150	0		29	10	S5820_150_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5820	151	0		29	10	S5820_151_0	3	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5820	151	0		29	10	S5820_151_0	3	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5820	151	0		29	10	S5820_151_0	3	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	58.50	175.50								58.50						160.50			175.50		58.50
S5820	151	0		29	10	S5820_151_0	3	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5825	017	0		29	10	S5825_017_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5825	017	0		29	10	S5825_017_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5825	017	0		29	10	S5825_017_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5825	085	0		29	10	S5825_085_0	1	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5825	085	0		29	10	S5825_085_0	1	2	4	3	Brand	000010	1	2	2			Brand																							Brand			Brand																						Brand																					
S5825	085	0		29	10	S5825_085_0	1	3	4	1	Specialty	010010	1	1				Specialty	110000000010000000000	34									34											34	Specialty	2	1	Specialty	33									33											33	Specialty																					
S5825	085	0		29	10	S5825_085_0	1	3	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5825	085	0		29	10	S5825_085_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00
S5825	085	0		29	10	S5825_085_0	1	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	44.00	88.00								44.00			88.00								44.00
S5840	002	0		29	10	S5840_002_0	6	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000000000	30	90								30											31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00											15.00
S5840	002	0		29	10	S5840_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000000000	30	90								30											31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00											30.00
S5840	002	0		29	10	S5840_002_0	6	4	4	1	Specialty Tier Brand	010011	1	1				Specialty Tier Brand	111000000010000000000	30	90								30											31	Specialty Tier Brand	2	1	Specialty Tier Brand	25	25								25											25	Specialty Tier Brand																					
S5840	002	0		29	10	S5840_002_0	6	1	4	1	Generic	010000	1	2				Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5840	002	0		29	10	S5840_002_0	6	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5840	002	0		29	10	S5840_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5840	002	0		29	10	S5840_002_0	6	4	4	3	Specialty Tier Brand	010011	1	1	2			Specialty Tier Brand																							Specialty Tier Brand			Specialty Tier Brand																						Specialty Tier Brand																					
S5840	002	0		29	10	S5840_002_0	6	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010000000000	30	90								30											31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00											5.00
S5857	001	0		29	10	S5857_001_0	3	1	3	1	Generic Drugs	010000		2				Generic Drugs	111000000010010000000	31	90								31										90	31	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	21.00								7.00			17.50								7.00
S5857	001	0		29	10	S5857_001_0	3	4	3	1	Specialty Tier	010010		1				Specialty Tier	110000000010000000000	31									31											31	Specialty Tier	2	1	Specialty Tier	33									33											33	Specialty Tier																					
S5857	001	0		29	10	S5857_001_0	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			162.50								65.00
S5857	001	0		29	10	S5857_001_0	3	2	3	1	Preferred Brand on Formulary	000001		2				Preferred Brand on Formulary	111000000010010000000	31	90								31										90	31	Preferred Brand on Formulary	2	2	Preferred Brand on Formulary																						Preferred Brand on Formulary	42.00	126.00								42.00			105.00								42.00
S5860	001	0		29	10	S5860_001_0	13	1	3	1	Generic drugs	010000		2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	8.75	26.25								8.75			17.50								8.75
S5860	001	0		29	10	S5860_001_0	13	2	3	1	Preferred brand drugs	000001		2				Preferred brand drugs	111000000010010000000	30	90								30										90	31	Preferred brand drugs	2	2	Preferred brand drugs																						Preferred brand drugs	39.00	117.00								39.00			78.00								39.00
S5860	001	0		29	10	S5860_001_0	13	3	3	1	Non-preferred brand drugs	100000		2				Non-preferred brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred brand drugs	2	2	Non-preferred brand drugs																						Non-preferred brand drugs	59.00	177.00								59.00			118.00								59.00
S5860	001	0		29	10	S5860_001_0	13	4	3	1	Specialty drugs	010010		1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	33	33								33			33								33	Specialty drugs																					
S5860	003	0		29	10	S5860_003_0	13	1	4	1	Generic drugs	010000	1	2				Generic drugs	111000000010010000000	30	90								30										90	31	Generic drugs	2	2	Generic drugs																						Generic drugs	9.00	27.00								9.00			18.00								9.00
S5860	003	0		29	10	S5860_003_0	13	2	4	1	Preferred brand drugs	000001	3	2				Preferred brand drugs	111000000010010000000	30	90								30										90	31	Preferred brand drugs	2	2	Preferred brand drugs																						Preferred brand drugs	40.00	120.00								40.00			80.00								40.00
S5860	003	0		29	10	S5860_003_0	13	3	4	1	Non-preferred brand drugs	100000	3	2				Non-preferred brand drugs	111000000010010000000	30	90								30										90	31	Non-preferred brand drugs	2	2	Non-preferred brand drugs																						Non-preferred brand drugs	60.00	180.00								60.00			120.00								60.00
S5860	003	0		29	10	S5860_003_0	13	4	4	1	Specialty drugs	010010	3	1				Specialty drugs	111000000010010000000	30	90								30										90	31	Specialty drugs	2	1	Specialty drugs	30	30								30			30								30	Specialty drugs																					
S5877	004	0		29	10	S5877_004_0	1	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	2.50	7.50								2.50			7.50								2.50
S5877	004	0		29	10	S5877_004_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00
S5877	004	0		29	10	S5877_004_0	1	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00
S5877	004	0		29	10	S5877_004_0	1	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	2	Specialty																						Specialty	50.00	150.00								50.00			150.00								50.00
S5877	007	0		29	10	S5877_007_0	1	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	20	20								20			20								20	Generic																					
S5877	007	0		29	10	S5877_007_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	25	25								25			25								25	Preferred Brand																					
S5877	007	0		29	10	S5877_007_0	1	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																					
S5877	007	0		29	10	S5877_007_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	30	30								30			30								30	Specialty																					
S5884	001	0		29	10	S5884_001_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	001	0		29	10	S5884_001_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	001	0		29	10	S5884_001_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	001	0		29	10	S5884_001_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	002	0		29	10	S5884_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	002	0		29	10	S5884_002_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	002	0		29	10	S5884_002_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	002	0		29	10	S5884_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	003	0		29	10	S5884_003_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	003	0		29	10	S5884_003_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	003	0		29	10	S5884_003_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	003	0		29	10	S5884_003_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	004	0		29	10	S5884_004_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	004	0		29	10	S5884_004_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	004	0		29	10	S5884_004_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	004	0		29	10	S5884_004_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	005	0		29	10	S5884_005_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	005	0		29	10	S5884_005_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	005	0		29	10	S5884_005_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	005	0		29	10	S5884_005_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	006	0		29	10	S5884_006_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	006	0		29	10	S5884_006_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	006	0		29	10	S5884_006_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	006	0		29	10	S5884_006_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	007	0		29	10	S5884_007_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	007	0		29	10	S5884_007_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	007	0		29	10	S5884_007_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	007	0		29	10	S5884_007_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	008	0		29	10	S5884_008_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	008	0		29	10	S5884_008_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	008	0		29	10	S5884_008_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	008	0		29	10	S5884_008_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	009	0		29	10	S5884_009_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	009	0		29	10	S5884_009_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	009	0		29	10	S5884_009_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	009	0		29	10	S5884_009_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	010	0		29	10	S5884_010_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	010	0		29	10	S5884_010_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	010	0		29	10	S5884_010_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	010	0		29	10	S5884_010_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	011	0		29	10	S5884_011_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	011	0		29	10	S5884_011_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	011	0		29	10	S5884_011_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	011	0		29	10	S5884_011_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	012	0		29	10	S5884_012_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	012	0		29	10	S5884_012_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	012	0		29	10	S5884_012_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	012	0		29	10	S5884_012_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	013	0		29	10	S5884_013_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	013	0		29	10	S5884_013_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	013	0		29	10	S5884_013_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	013	0		29	10	S5884_013_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	014	0		29	10	S5884_014_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	014	0		29	10	S5884_014_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	014	0		29	10	S5884_014_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	014	0		29	10	S5884_014_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	015	0		29	10	S5884_015_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	015	0		29	10	S5884_015_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	015	0		29	10	S5884_015_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	015	0		29	10	S5884_015_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	016	0		29	10	S5884_016_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	016	0		29	10	S5884_016_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	016	0		29	10	S5884_016_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	016	0		29	10	S5884_016_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	017	0		29	10	S5884_017_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	017	0		29	10	S5884_017_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	017	0		29	10	S5884_017_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	017	0		29	10	S5884_017_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	018	0		29	10	S5884_018_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	018	0		29	10	S5884_018_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	018	0		29	10	S5884_018_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	018	0		29	10	S5884_018_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	019	0		29	10	S5884_019_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	019	0		29	10	S5884_019_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	019	0		29	10	S5884_019_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	019	0		29	10	S5884_019_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	020	0		29	10	S5884_020_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	020	0		29	10	S5884_020_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	020	0		29	10	S5884_020_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	020	0		29	10	S5884_020_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	021	0		29	10	S5884_021_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	021	0		29	10	S5884_021_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	021	0		29	10	S5884_021_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	021	0		29	10	S5884_021_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	022	0		29	10	S5884_022_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	022	0		29	10	S5884_022_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	022	0		29	10	S5884_022_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	022	0		29	10	S5884_022_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	023	0		29	10	S5884_023_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	023	0		29	10	S5884_023_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	023	0		29	10	S5884_023_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	023	0		29	10	S5884_023_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	024	0		29	10	S5884_024_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	024	0		29	10	S5884_024_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	024	0		29	10	S5884_024_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	024	0		29	10	S5884_024_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	025	0		29	10	S5884_025_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	025	0		29	10	S5884_025_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	025	0		29	10	S5884_025_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	025	0		29	10	S5884_025_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	026	0		29	10	S5884_026_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	026	0		29	10	S5884_026_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	026	0		29	10	S5884_026_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	026	0		29	10	S5884_026_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	027	0		29	10	S5884_027_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	027	0		29	10	S5884_027_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	027	0		29	10	S5884_027_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	027	0		29	10	S5884_027_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	028	0		29	10	S5884_028_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	028	0		29	10	S5884_028_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	028	0		29	10	S5884_028_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	028	0		29	10	S5884_028_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	029	0		29	10	S5884_029_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	029	0		29	10	S5884_029_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	029	0		29	10	S5884_029_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	029	0		29	10	S5884_029_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	030	0		29	10	S5884_030_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	030	0		29	10	S5884_030_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	030	0		29	10	S5884_030_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	030	0		29	10	S5884_030_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	031	0		29	10	S5884_031_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	031	0		29	10	S5884_031_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	031	0		29	10	S5884_031_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	031	0		29	10	S5884_031_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	031	0		29	10	S5884_031_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	031	0		29	10	S5884_031_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	031	0		29	10	S5884_031_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	031	0		29	10	S5884_031_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	032	0		29	10	S5884_032_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	032	0		29	10	S5884_032_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	032	0		29	10	S5884_032_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	032	0		29	10	S5884_032_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	032	0		29	10	S5884_032_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	032	0		29	10	S5884_032_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	032	0		29	10	S5884_032_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	032	0		29	10	S5884_032_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	033	0		29	10	S5884_033_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	033	0		29	10	S5884_033_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	033	0		29	10	S5884_033_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	033	0		29	10	S5884_033_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	033	0		29	10	S5884_033_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	033	0		29	10	S5884_033_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	033	0		29	10	S5884_033_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	033	0		29	10	S5884_033_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	034	0		29	10	S5884_034_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	034	0		29	10	S5884_034_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	034	0		29	10	S5884_034_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	034	0		29	10	S5884_034_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	034	0		29	10	S5884_034_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	034	0		29	10	S5884_034_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	034	0		29	10	S5884_034_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	034	0		29	10	S5884_034_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	035	0		29	10	S5884_035_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	035	0		29	10	S5884_035_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	035	0		29	10	S5884_035_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	035	0		29	10	S5884_035_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	035	0		29	10	S5884_035_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	035	0		29	10	S5884_035_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	035	0		29	10	S5884_035_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	035	0		29	10	S5884_035_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	036	0		29	10	S5884_036_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	036	0		29	10	S5884_036_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	036	0		29	10	S5884_036_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	036	0		29	10	S5884_036_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	036	0		29	10	S5884_036_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	036	0		29	10	S5884_036_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	036	0		29	10	S5884_036_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	036	0		29	10	S5884_036_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	037	0		29	10	S5884_037_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	037	0		29	10	S5884_037_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	037	0		29	10	S5884_037_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	037	0		29	10	S5884_037_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	037	0		29	10	S5884_037_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	037	0		29	10	S5884_037_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	037	0		29	10	S5884_037_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	037	0		29	10	S5884_037_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	038	0		29	10	S5884_038_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	038	0		29	10	S5884_038_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	038	0		29	10	S5884_038_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	038	0		29	10	S5884_038_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	038	0		29	10	S5884_038_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	038	0		29	10	S5884_038_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	038	0		29	10	S5884_038_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	038	0		29	10	S5884_038_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	039	0		29	10	S5884_039_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	039	0		29	10	S5884_039_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	039	0		29	10	S5884_039_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	039	0		29	10	S5884_039_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	039	0		29	10	S5884_039_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	039	0		29	10	S5884_039_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	039	0		29	10	S5884_039_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	039	0		29	10	S5884_039_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	040	0		29	10	S5884_040_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	040	0		29	10	S5884_040_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	040	0		29	10	S5884_040_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	040	0		29	10	S5884_040_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	040	0		29	10	S5884_040_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	040	0		29	10	S5884_040_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	040	0		29	10	S5884_040_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	040	0		29	10	S5884_040_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	041	0		29	10	S5884_041_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	041	0		29	10	S5884_041_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	041	0		29	10	S5884_041_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	041	0		29	10	S5884_041_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	041	0		29	10	S5884_041_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	041	0		29	10	S5884_041_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	041	0		29	10	S5884_041_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	041	0		29	10	S5884_041_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	042	0		29	10	S5884_042_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	042	0		29	10	S5884_042_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	042	0		29	10	S5884_042_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	042	0		29	10	S5884_042_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	042	0		29	10	S5884_042_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	042	0		29	10	S5884_042_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	042	0		29	10	S5884_042_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	042	0		29	10	S5884_042_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	043	0		29	10	S5884_043_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	043	0		29	10	S5884_043_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	043	0		29	10	S5884_043_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	043	0		29	10	S5884_043_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	043	0		29	10	S5884_043_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	043	0		29	10	S5884_043_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	043	0		29	10	S5884_043_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	043	0		29	10	S5884_043_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	044	0		29	10	S5884_044_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	044	0		29	10	S5884_044_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	044	0		29	10	S5884_044_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	044	0		29	10	S5884_044_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	044	0		29	10	S5884_044_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	044	0		29	10	S5884_044_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	044	0		29	10	S5884_044_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	044	0		29	10	S5884_044_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	045	0		29	10	S5884_045_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	045	0		29	10	S5884_045_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	045	0		29	10	S5884_045_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	045	0		29	10	S5884_045_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	045	0		29	10	S5884_045_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	045	0		29	10	S5884_045_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	045	0		29	10	S5884_045_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	045	0		29	10	S5884_045_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	046	0		29	10	S5884_046_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	046	0		29	10	S5884_046_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	046	0		29	10	S5884_046_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	046	0		29	10	S5884_046_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	046	0		29	10	S5884_046_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	046	0		29	10	S5884_046_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	046	0		29	10	S5884_046_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	046	0		29	10	S5884_046_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	047	0		29	10	S5884_047_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	047	0		29	10	S5884_047_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	047	0		29	10	S5884_047_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	047	0		29	10	S5884_047_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	047	0		29	10	S5884_047_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	047	0		29	10	S5884_047_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	047	0		29	10	S5884_047_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	047	0		29	10	S5884_047_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	048	0		29	10	S5884_048_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	048	0		29	10	S5884_048_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	048	0		29	10	S5884_048_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	048	0		29	10	S5884_048_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	048	0		29	10	S5884_048_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	048	0		29	10	S5884_048_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	048	0		29	10	S5884_048_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	048	0		29	10	S5884_048_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	049	0		29	10	S5884_049_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	049	0		29	10	S5884_049_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	049	0		29	10	S5884_049_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	049	0		29	10	S5884_049_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	049	0		29	10	S5884_049_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	049	0		29	10	S5884_049_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	049	0		29	10	S5884_049_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	049	0		29	10	S5884_049_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	050	0		29	10	S5884_050_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	050	0		29	10	S5884_050_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	050	0		29	10	S5884_050_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	050	0		29	10	S5884_050_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	050	0		29	10	S5884_050_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	050	0		29	10	S5884_050_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	050	0		29	10	S5884_050_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	050	0		29	10	S5884_050_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	051	0		29	10	S5884_051_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	051	0		29	10	S5884_051_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	051	0		29	10	S5884_051_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	051	0		29	10	S5884_051_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	051	0		29	10	S5884_051_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	051	0		29	10	S5884_051_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	051	0		29	10	S5884_051_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	051	0		29	10	S5884_051_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	052	0		29	10	S5884_052_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	052	0		29	10	S5884_052_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	052	0		29	10	S5884_052_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	052	0		29	10	S5884_052_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	052	0		29	10	S5884_052_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	052	0		29	10	S5884_052_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	052	0		29	10	S5884_052_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	052	0		29	10	S5884_052_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	053	0		29	10	S5884_053_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	053	0		29	10	S5884_053_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	053	0		29	10	S5884_053_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	053	0		29	10	S5884_053_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	053	0		29	10	S5884_053_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	053	0		29	10	S5884_053_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	053	0		29	10	S5884_053_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	053	0		29	10	S5884_053_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	054	0		29	10	S5884_054_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	054	0		29	10	S5884_054_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	054	0		29	10	S5884_054_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	054	0		29	10	S5884_054_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	054	0		29	10	S5884_054_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	054	0		29	10	S5884_054_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	054	0		29	10	S5884_054_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	054	0		29	10	S5884_054_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	055	0		29	10	S5884_055_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	055	0		29	10	S5884_055_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	055	0		29	10	S5884_055_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	055	0		29	10	S5884_055_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	055	0		29	10	S5884_055_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	055	0		29	10	S5884_055_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	055	0		29	10	S5884_055_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	055	0		29	10	S5884_055_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	056	0		29	10	S5884_056_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	056	0		29	10	S5884_056_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	056	0		29	10	S5884_056_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	056	0		29	10	S5884_056_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	056	0		29	10	S5884_056_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	056	0		29	10	S5884_056_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	056	0		29	10	S5884_056_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	056	0		29	10	S5884_056_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	057	0		29	10	S5884_057_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	057	0		29	10	S5884_057_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	057	0		29	10	S5884_057_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	057	0		29	10	S5884_057_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	057	0		29	10	S5884_057_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	057	0		29	10	S5884_057_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	057	0		29	10	S5884_057_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	057	0		29	10	S5884_057_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	058	0		29	10	S5884_058_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	058	0		29	10	S5884_058_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	058	0		29	10	S5884_058_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	058	0		29	10	S5884_058_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	058	0		29	10	S5884_058_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	058	0		29	10	S5884_058_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	058	0		29	10	S5884_058_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	058	0		29	10	S5884_058_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	059	0		29	10	S5884_059_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	059	0		29	10	S5884_059_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	059	0		29	10	S5884_059_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	059	0		29	10	S5884_059_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	059	0		29	10	S5884_059_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	059	0		29	10	S5884_059_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	059	0		29	10	S5884_059_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	059	0		29	10	S5884_059_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	060	0		29	10	S5884_060_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	060	0		29	10	S5884_060_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	060	0		29	10	S5884_060_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	060	0		29	10	S5884_060_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	060	0		29	10	S5884_060_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	060	0		29	10	S5884_060_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	060	0		29	10	S5884_060_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	060	0		29	10	S5884_060_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	061	0		29	10	S5884_061_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	061	0		29	10	S5884_061_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	061	0		29	10	S5884_061_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	062	0		29	10	S5884_062_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	062	0		29	10	S5884_062_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	062	0		29	10	S5884_062_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	40	40								40		40	40								40	Other - Non-Preferred (Gen/Brand)																					
S5884	063	0		29	10	S5884_063_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	063	0		29	10	S5884_063_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	063	0		29	10	S5884_063_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	43	43								43		43	43								43	Other - Non-Preferred (Gen/Brand)																					
S5884	064	0		29	10	S5884_064_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	064	0		29	10	S5884_064_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	064	0		29	10	S5884_064_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	46	46								46		46	46								46	Other - Non-Preferred (Gen/Brand)																					
S5884	065	0		29	10	S5884_065_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	065	0		29	10	S5884_065_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	065	0		29	10	S5884_065_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	066	0		29	10	S5884_066_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	066	0		29	10	S5884_066_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	066	0		29	10	S5884_066_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	067	0		29	10	S5884_067_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	067	0		29	10	S5884_067_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	46	46								46		46	46								46	Other - Non-Preferred (Gen/Brand)																					
S5884	067	0		29	10	S5884_067_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	068	0		29	10	S5884_068_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	068	0		29	10	S5884_068_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	46	46								46		46	46								46	Other - Non-Preferred (Gen/Brand)																					
S5884	068	0		29	10	S5884_068_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	069	0		29	10	S5884_069_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	40	40								40		40	40								40	Other - Non-Preferred (Gen/Brand)																					
S5884	069	0		29	10	S5884_069_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	069	0		29	10	S5884_069_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	070	0		29	10	S5884_070_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	44	44								44		44	44								44	Other - Non-Preferred (Gen/Brand)																					
S5884	070	0		29	10	S5884_070_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	070	0		29	10	S5884_070_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	071	0		29	10	S5884_071_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	071	0		29	10	S5884_071_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	071	0		29	10	S5884_071_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	072	0		29	10	S5884_072_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	072	0		29	10	S5884_072_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	072	0		29	10	S5884_072_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	073	0		29	10	S5884_073_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	073	0		29	10	S5884_073_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	073	0		29	10	S5884_073_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	074	0		29	10	S5884_074_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	074	0		29	10	S5884_074_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	074	0		29	10	S5884_074_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	075	0		29	10	S5884_075_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	075	0		29	10	S5884_075_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	075	0		29	10	S5884_075_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	43	43								43		43	43								43	Other - Non-Preferred (Gen/Brand)																					
S5884	076	0		29	10	S5884_076_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	076	0		29	10	S5884_076_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	076	0		29	10	S5884_076_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	48	48								48		48	48								48	Other - Non-Preferred (Gen/Brand)																					
S5884	077	0		29	10	S5884_077_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	077	0		29	10	S5884_077_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	48	48								48		48	48								48	Other - Non-Preferred (Gen/Brand)																					
S5884	077	0		29	10	S5884_077_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	078	0		29	10	S5884_078_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	44	44								44		44	44								44	Other - Non-Preferred (Gen/Brand)																					
S5884	078	0		29	10	S5884_078_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	078	0		29	10	S5884_078_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	079	0		29	10	S5884_079_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	079	0		29	10	S5884_079_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	079	0		29	10	S5884_079_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	080	0		29	10	S5884_080_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	080	0		29	10	S5884_080_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	080	0		29	10	S5884_080_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	41	41								41		41	41								41	Other - Non-Preferred (Gen/Brand)																					
S5884	081	0		29	10	S5884_081_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	081	0		29	10	S5884_081_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	081	0		29	10	S5884_081_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	48	48								48		48	48								48	Other - Non-Preferred (Gen/Brand)																					
S5884	082	0		29	10	S5884_082_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	44	44								44		44	44								44	Other - Non-Preferred (Gen/Brand)																					
S5884	082	0		29	10	S5884_082_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	082	0		29	10	S5884_082_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	083	0		29	10	S5884_083_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	083	0		29	10	S5884_083_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	083	0		29	10	S5884_083_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	48	48								48		48	48								48	Other - Non-Preferred (Gen/Brand)																					
S5884	084	0		29	10	S5884_084_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	084	0		29	10	S5884_084_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	084	0		29	10	S5884_084_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	50	50								50		50	50								50	Other - Non-Preferred (Gen/Brand)																					
S5884	085	0		29	10	S5884_085_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	46	46								46		46	46								46	Other - Non-Preferred (Gen/Brand)																					
S5884	085	0		29	10	S5884_085_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	085	0		29	10	S5884_085_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	086	0		29	10	S5884_086_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	48	48								48		48	48								48	Other - Non-Preferred (Gen/Brand)																					
S5884	086	0		29	10	S5884_086_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	086	0		29	10	S5884_086_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	087	0		29	10	S5884_087_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	087	0		29	10	S5884_087_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	44	44								44		44	44								44	Other - Non-Preferred (Gen/Brand)																					
S5884	087	0		29	10	S5884_087_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	088	0		29	10	S5884_088_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	088	0		29	10	S5884_088_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	088	0		29	10	S5884_088_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	089	0		29	10	S5884_089_0	1	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	089	0		29	10	S5884_089_0	1	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	43	43								43		43	43								43	Other - Non-Preferred (Gen/Brand)																					
S5884	089	0		29	10	S5884_089_0	1	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	090	0		29	10	S5884_090_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	090	0		29	10	S5884_090_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	42	42								42		42	42								42	Other - Non-Preferred (Gen/Brand)																					
S5884	090	0		29	10	S5884_090_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	092	0		29	10	S5884_092_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	092	0		29	10	S5884_092_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	092	0		29	10	S5884_092_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	45	45								45		45	45								45	Other - Non-Preferred (Gen/Brand)																					
S5884	093	0		29	10	S5884_093_0	3	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	093	0		29	10	S5884_093_0	3	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	093	0		29	10	S5884_093_0	3	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	094	0		29	10	S5884_094_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25								25		25	25								25	Preferred Brand																					
S5884	094	0		29	10	S5884_094_0	2	1	2	1	Preferred Generic	001000		2				Preferred Generic	111000000010110000000	30	90								30		30								90	34	Preferred Generic	2	1	Preferred Generic	15	15								15		15	15								15	Preferred Generic																					
S5884	094	0		29	10	S5884_094_0	2	3	2	1	Other - Non-Preferred (Gen/Brand)	100100		2				Other - Non-Preferred (Gen/Brand)	111000000010110000000	30	90								30		30								90	34	Other - Non-Preferred (Gen/Brand)	2	1	Other - Non-Preferred (Gen/Brand)	47	47								47		47	47								47	Other - Non-Preferred (Gen/Brand)																					
S5884	095	0		29	10	S5884_095_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	095	0		29	10	S5884_095_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	095	0		29	10	S5884_095_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	095	0		29	10	S5884_095_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	096	0		29	10	S5884_096_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	096	0		29	10	S5884_096_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	096	0		29	10	S5884_096_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	096	0		29	10	S5884_096_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	097	0		29	10	S5884_097_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	097	0		29	10	S5884_097_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	097	0		29	10	S5884_097_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	097	0		29	10	S5884_097_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	098	0		29	10	S5884_098_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	098	0		29	10	S5884_098_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	098	0		29	10	S5884_098_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	098	0		29	10	S5884_098_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	098	0		29	10	S5884_098_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	098	0		29	10	S5884_098_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	098	0		29	10	S5884_098_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	098	0		29	10	S5884_098_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	099	0		29	10	S5884_099_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	099	0		29	10	S5884_099_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	099	0		29	10	S5884_099_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	099	0		29	10	S5884_099_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5884	099	0		29	10	S5884_099_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	099	0		29	10	S5884_099_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	099	0		29	10	S5884_099_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	099	0		29	10	S5884_099_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	100	0		29	10	S5884_100_0	2	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	100	0		29	10	S5884_100_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00
S5884	100	0		29	10	S5884_100_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010000110110	30	90								30				30	90		30	90			34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00
S5884	100	0		29	10	S5884_100_0	2	4	4	3	Specialty	100100	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5884	100	0		29	10	S5884_100_0	2	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111000000010000110110	30	90								30				30	90		30	90			34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00
S5884	100	0		29	10	S5884_100_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5884	100	0		29	10	S5884_100_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5884	100	0		29	10	S5884_100_0	2	4	4	1	Specialty	100100	1	1				Specialty	110000000010000100100	30									30				30			30				34	Specialty	2	1	Specialty	33									33					33			33			33	Specialty																					
S5904	001	0		29	10	S5904_001_0	4	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
S5904	001	0		29	10	S5904_001_0	4	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
S5904	001	0		29	10	S5904_001_0	4	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
S5904	001	0		29	10	S5904_001_0	4	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
S5904	002	0		29	10	S5904_002_0	4	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	40.00	120.00	80.00							40.00		40.00	80.00	80.00							40.00
S5904	002	0		29	10	S5904_002_0	4	1	4	1	Tier 1 - Covered Generic	010000	3	2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
S5904	002	0		29	10	S5904_002_0	4	2	4	3	Tier 2 - Covered Preferred Brand	000001	1	2	2			Tier 2 - Covered Preferred Brand																							Tier 2 - Covered Preferred Brand			Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand																					
S5904	002	0		29	10	S5904_002_0	4	1	4	3	Tier 1 - Covered Generic	010000	3	2	1		1	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
S5904	002	0		29	10	S5904_002_0	4	3	4	3	Tier 3 - Covered Brand	100000	1	2	2			Tier 3 - Covered Brand																							Tier 3 - Covered Brand			Tier 3 - Covered Brand																						Tier 3 - Covered Brand																					
S5904	002	0		29	10	S5904_002_0	4	3	4	1	Tier 3 - Covered Brand	100000	1	2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	83.00	249.00	166.00							83.00		83.00	166.00	166.00							83.00
S5904	002	0		29	10	S5904_002_0	4	4	4	1	Tier S - Covered Specialty	110001	1	1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																					
S5904	002	0		29	10	S5904_002_0	4	4	4	3	Tier S - Covered Specialty	110001	1	1	2			Tier S - Covered Specialty																							Tier S - Covered Specialty			Tier S - Covered Specialty																						Tier S - Covered Specialty																					
S5904	003	0		29	10	S5904_003_0	5	2	3	1	Tier 2 - Covered Preferred Brand	000001		2				Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 2 - Covered Preferred Brand	2	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	45.00	135.00	90.00							45.00		45.00	90.00	90.00							45.00
S5904	003	0		29	10	S5904_003_0	5	1	3	1	Tier 1 - Covered Generic	010000		2				Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	60							90	31	Tier 1 - Covered Generic	2	2	Tier 1 - Covered Generic																						Tier 1 - Covered Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00
S5904	003	0		29	10	S5904_003_0	5	3	3	1	Tier 3 - Covered Brand	100000		2				Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	60							90	31	Tier 3 - Covered Brand	2	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	90.00	270.00	180.00							90.00		90.00	180.00	180.00							90.00
S5904	003	0		29	10	S5904_003_0	5	4	3	1	Tier S - Covered Specialty	110001		1				Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	60							90	31	Tier S - Covered Specialty	2	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																					
S5907	001	0		29	10	S5907_001_0	4	5	2	1	Tier 5/ Nivel 5	010010		1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
S5907	001	0		29	10	S5907_001_0	4	4	2	1	Tier 4/ Nivel 4	100000		2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	3	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	30.00	90.00	30.00							30.00			90.00								30.00
S5907	001	0		29	10	S5907_001_0	4	3	2	1	Tier 3/ Nivel 3	000010		2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	30.00	90.00	30.00							30.00			90.00								30.00
S5907	001	0		29	10	S5907_001_0	4	1	2	1	Tier 1/ Nivel 1	010000		2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
S5907	001	0		29	10	S5907_001_0	4	2	2	1	Tier 2/ Nivel 2	000001		2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	1	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	20.00	60.00	20.00							20.00			60.00								20.00
S5907	002	0		29	10	S5907_002_0	4	1	4	1	Tier 1/ Nivel 1	010000	1	2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
S5907	002	0		29	10	S5907_002_0	4	2	4	1	Tier 2/ Nivel 2	000001	1	2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	1	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	35.00	105.00	35.00							35.00			105.00								35.00
S5907	002	0		29	10	S5907_002_0	4	3	4	1	Tier 3/ Nivel 3	000010	1	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	50.00	150.00	50.00							50.00			150.00								50.00
S5907	002	0		29	10	S5907_002_0	4	4	4	1	Tier 4/ Nivel 4	100000	1	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	3	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	50.00	150.00	50.00							50.00			150.00								50.00
S5907	002	0		29	10	S5907_002_0	4	5	4	1	Tier 5/ Nivel 5	010010	1	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
S5907	003	0		29	10	S5907_003_0	4	4	4	1	Tier 4/ Nivel 4	100000	1	2				Tier 4/ Nivel 4	111100000010010000000	30	90	15							30										90	31	Tier 4/ Nivel 4	1	3	Tier 4/ Nivel 4	25	25	25							25			25								25	Tier 4/ Nivel 4	50.00	150.00	50.00							50.00			150.00								50.00
S5907	003	0		29	10	S5907_003_0	4	3	4	1	Tier 3/ Nivel 3	000010	1	2				Tier 3/ Nivel 3	111100000010010000000	30	90	15							30										90	31	Tier 3/ Nivel 3	1	2	Tier 3/ Nivel 3																						Tier 3/ Nivel 3	50.00	150.00	50.00							50.00			150.00								50.00
S5907	003	0		29	10	S5907_003_0	4	2	4	1	Tier 2/ Nivel 2	000001	1	2				Tier 2/ Nivel 2	111100000010010000000	30	90	15							30										90	31	Tier 2/ Nivel 2	1	2	Tier 2/ Nivel 2																						Tier 2/ Nivel 2	30.00	90.00	30.00							30.00			90.00								30.00
S5907	003	0		29	10	S5907_003_0	4	1	4	1	Tier 1/ Nivel 1	010000	1	2				Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
S5907	003	0		29	10	S5907_003_0	4	5	4	1	Tier 5/ Nivel 5	010010	1	1				Tier 5/ Nivel 5	111100000010010000000	30	90	15							30										90	31	Tier 5/ Nivel 5	2	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																					
S5907	003	0		29	10	S5907_003_0	4	1	4	3	Tier 1/ Nivel 1	010000	1	2	1		1	Tier 1/ Nivel 1	111100000010010000000	30	90	15							30										90	31	Tier 1/ Nivel 1	1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00
S5907	003	0		29	10	S5907_003_0	4	2	4	3	Tier 2/ Nivel 2	000001	1	2	2			Tier 2/ Nivel 2																							Tier 2/ Nivel 2			Tier 2/ Nivel 2																						Tier 2/ Nivel 2																					
S5907	003	0		29	10	S5907_003_0	4	5	4	3	Tier 5/ Nivel 5	010010	1	1	2			Tier 5/ Nivel 5																							Tier 5/ Nivel 5			Tier 5/ Nivel 5																						Tier 5/ Nivel 5																					
S5907	003	0		29	10	S5907_003_0	4	4	4	3	Tier 4/ Nivel 4	100000	1	2	2			Tier 4/ Nivel 4																							Tier 4/ Nivel 4			Tier 4/ Nivel 4																						Tier 4/ Nivel 4																					
S5907	003	0		29	10	S5907_003_0	4	3	4	3	Tier 3/ Nivel 3	000010	1	2	2			Tier 3/ Nivel 3																							Tier 3/ Nivel 3			Tier 3/ Nivel 3																						Tier 3/ Nivel 3																					
S5915	002	0		29	10	S5915_002_0	4	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00								0.00
S5915	002	0		29	10	S5915_002_0	4	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
S5915	002	0		29	10	S5915_002_0	4	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	65.00	195.00	130.00							65.00		65.00	130.00								65.00
S5915	002	0		29	10	S5915_002_0	4	4	4	3	Specialty	111111	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5915	002	0		29	10	S5915_002_0	4	3	4	3	Non-Preferred Brand or Generic	100100	1	2	2			Non-Preferred Brand or Generic																							Non-Preferred Brand or Generic			Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																					
S5915	002	0		29	10	S5915_002_0	4	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5915	002	0		29	10	S5915_002_0	4	1	4	3	Preferred Generic	001000	1	2	1		1	Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00
S5915	002	0		29	10	S5915_002_0	4	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
S5915	003	0		29	10	S5915_003_0	4	1	3	1	Preferred Generic	001000		2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00
S5915	003	0		29	10	S5915_003_0	4	3	3	1	Non-Preferred Brand or Generic	100100		2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	1	Non-Preferred Brand or Generic	38	38	38							38		38	38								38	Non-Preferred Brand or Generic																					
S5915	003	0		29	10	S5915_003_0	4	2	3	1	Preferred Brand	000001		2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	1	Preferred Brand	25	25	25							25		25	25								25	Preferred Brand																					
S5915	004	0		29	10	S5915_004_0	5	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111100000010110000000	30	90	60							30		30								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00								35.00
S5915	004	0		29	10	S5915_004_0	5	3	4	1	Non-Preferred Brand or Generic	100100	1	2				Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30								90	34	Non-Preferred Brand or Generic	2	2	Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic	65.00	195.00	130.00							65.00		65.00	130.00								65.00
S5915	004	0		29	10	S5915_004_0	5	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111100000010110000000	30	90	60							30		30								90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	8.00	24.00	16.00							8.00		8.00	16.00								8.00
S5915	004	0		29	10	S5915_004_0	5	4	4	1	Specialty	111111	1	1				Specialty	111100000010110000000	30	90	60							30		30								90	34	Specialty	2	1	Specialty	33	33	33							33		33	33								33	Specialty																					
S5916	001	0		29	10	S5916_001_0	2	5	2	1	Specialty	110001		1				Specialty	110000000010100000000	30									30		30									31	Specialty	2	1	Specialty	25									25		25									25	Specialty																					
S5916	001	0		29	10	S5916_001_0	2	4	2	1	Miscellaneous Injectables	110001		2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
S5916	001	0		29	10	S5916_001_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00
S5916	001	0		29	10	S5916_001_0	2	1	2	1	Generic	001000		2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5916	001	0		29	10	S5916_001_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00
S5916	002	0		29	10	S5916_002_0	2	5	4	3	Specialty Medications	110001	1	1	2			Specialty Medications																							Specialty Medications			Specialty Medications																						Specialty Medications																					
S5916	002	0		29	10	S5916_002_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5916	002	0		29	10	S5916_002_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5916	002	0		29	10	S5916_002_0	2	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5916	002	0		29	10	S5916_002_0	2	5	4	1	Specialty Medications	110001	1	1				Specialty Medications	110000000010100000000	30									30		30									31	Specialty Medications	2	1	Specialty Medications	25									25		25									25	Specialty Medications																					
S5916	002	0		29	10	S5916_002_0	2	4	4	1	Miscellaneous Injectables	110001	1	2				Miscellaneous Injectables	110000000010100000000	30									30		30									31	Miscellaneous Injectables	2	1	Miscellaneous Injectables	25									25		25									25	Miscellaneous Injectables																					
S5916	002	0		29	10	S5916_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010110000000	30	90								30		30								90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	150.00								50.00
S5916	002	0		29	10	S5916_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010110000000	30	90								30		30								90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00
S5916	002	0		29	10	S5916_002_0	2	1	4	1	Generic	001000	1	2				Generic	111000000010110000000	30	90								30		30								90	31	Generic	2	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00
S5916	002	0		29	10	S5916_002_0	2	4	4	3	Miscellaneous Injectables	110001	1	2	2			Miscellaneous Injectables																							Miscellaneous Injectables			Miscellaneous Injectables																						Miscellaneous Injectables																					
S5917	001	0		29	10	S5917_001_0	4	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	50.00	150.00								50.00			150.00								50.00
S5917	001	0		29	10	S5917_001_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.75	29.25								9.75			29.25								9.75
S5917	001	0		29	10	S5917_001_0	4	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	002	0		29	10	S5917_002_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			24.00								8.00
S5917	002	0		29	10	S5917_002_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00			135.00								45.00
S5917	002	0		29	10	S5917_002_0	4	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	003	0		29	10	S5917_003_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00
S5917	003	0		29	10	S5917_003_0	4	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	50.00	150.00								50.00			150.00								50.00
S5917	003	0		29	10	S5917_003_0	4	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	004	0		29	10	S5917_004_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00			135.00								45.00
S5917	004	0		29	10	S5917_004_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			24.00								8.00
S5917	004	0		29	10	S5917_004_0	4	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	005	0		29	10	S5917_005_0	4	2	4	1	Brand	000010	1	2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	50.00	150.00								50.00			150.00								50.00
S5917	005	0		29	10	S5917_005_0	4	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			24.00								8.00
S5917	005	0		29	10	S5917_005_0	4	3	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	006	0		29	10	S5917_006_0	4	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00			135.00								45.00
S5917	006	0		29	10	S5917_006_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.25	27.75								9.25			27.75								9.25
S5917	006	0		29	10	S5917_006_0	4	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	007	0		29	10	S5917_007_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.75	29.25								9.75			29.25								9.75
S5917	007	0		29	10	S5917_007_0	4	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	45.00	135.00								45.00			135.00								45.00
S5917	007	0		29	10	S5917_007_0	4	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5917	008	0		29	10	S5917_008_0	4	1	3	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	9.75	29.25								9.75			29.25								9.75
S5917	008	0		29	10	S5917_008_0	4	2	3	1	Brand	000010		2				Brand	111000000010010000000	30	90								30										90	31	Brand	2	2	Brand																						Brand	50.00	150.00								50.00			150.00								50.00
S5917	008	0		29	10	S5917_008_0	4	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5921	001	0		29	10	S5921_001_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	51.65	154.95								51.65						139.95			154.95		51.65
S5921	001	0		29	10	S5921_001_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	001	0		29	10	S5921_001_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	001	0		29	10	S5921_001_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	002	0		29	10	S5921_002_0	4	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	002	0		29	10	S5921_002_0	4	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	002	0		29	10	S5921_002_0	4	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	002	0		29	10	S5921_002_0	4	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	003	0		29	10	S5921_003_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	003	0		29	10	S5921_003_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	003	0		29	10	S5921_003_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	003	0		29	10	S5921_003_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	003	0		29	10	S5921_003_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	003	0		29	10	S5921_003_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	003	0		29	10	S5921_003_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	003	0		29	10	S5921_003_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	011	0		29	10	S5921_011_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	51.95	155.85								51.95						140.85			155.85		51.95
S5921	011	0		29	10	S5921_011_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	011	0		29	10	S5921_011_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	011	0		29	10	S5921_011_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	012	0		29	10	S5921_012_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	87.00	261.00								87.00						246.00			261.00		87.00
S5921	012	0		29	10	S5921_012_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	012	0		29	10	S5921_012_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	012	0		29	10	S5921_012_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	013	0		29	10	S5921_013_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	013	0		29	10	S5921_013_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	013	0		29	10	S5921_013_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	013	0		29	10	S5921_013_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	013	0		29	10	S5921_013_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	013	0		29	10	S5921_013_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	013	0		29	10	S5921_013_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	013	0		29	10	S5921_013_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	021	0		29	10	S5921_021_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	61.10	183.30								61.10						168.30			183.30		61.10
S5921	021	0		29	10	S5921_021_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	021	0		29	10	S5921_021_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	021	0		29	10	S5921_021_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	022	0		29	10	S5921_022_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	94.00	282.00								94.00						267.00			282.00		94.00
S5921	022	0		29	10	S5921_022_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	022	0		29	10	S5921_022_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	022	0		29	10	S5921_022_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	023	0		29	10	S5921_023_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	023	0		29	10	S5921_023_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	023	0		29	10	S5921_023_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	023	0		29	10	S5921_023_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	023	0		29	10	S5921_023_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	023	0		29	10	S5921_023_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	023	0		29	10	S5921_023_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	023	0		29	10	S5921_023_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	031	0		29	10	S5921_031_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	031	0		29	10	S5921_031_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	031	0		29	10	S5921_031_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	031	0		29	10	S5921_031_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	66.30	198.90								66.30						183.90			198.90		66.30
S5921	032	0		29	10	S5921_032_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	032	0		29	10	S5921_032_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	94.00	282.00								94.00						267.00			282.00		94.00
S5921	032	0		29	10	S5921_032_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	032	0		29	10	S5921_032_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	033	0		29	10	S5921_033_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	033	0		29	10	S5921_033_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	033	0		29	10	S5921_033_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	033	0		29	10	S5921_033_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	033	0		29	10	S5921_033_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	033	0		29	10	S5921_033_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	033	0		29	10	S5921_033_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	033	0		29	10	S5921_033_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	041	0		29	10	S5921_041_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	64.85	194.55								64.85						179.55			194.55		64.85
S5921	041	0		29	10	S5921_041_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	041	0		29	10	S5921_041_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	041	0		29	10	S5921_041_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	042	0		29	10	S5921_042_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	042	0		29	10	S5921_042_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	042	0		29	10	S5921_042_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	042	0		29	10	S5921_042_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	043	0		29	10	S5921_043_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	043	0		29	10	S5921_043_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	043	0		29	10	S5921_043_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	043	0		29	10	S5921_043_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	043	0		29	10	S5921_043_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	043	0		29	10	S5921_043_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	043	0		29	10	S5921_043_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	043	0		29	10	S5921_043_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	051	0		29	10	S5921_051_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	62.20	186.60								62.20						171.60			186.60		62.20
S5921	051	0		29	10	S5921_051_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	051	0		29	10	S5921_051_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	051	0		29	10	S5921_051_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	052	0		29	10	S5921_052_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	052	0		29	10	S5921_052_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	052	0		29	10	S5921_052_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	052	0		29	10	S5921_052_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	053	0		29	10	S5921_053_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	053	0		29	10	S5921_053_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	053	0		29	10	S5921_053_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	053	0		29	10	S5921_053_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	053	0		29	10	S5921_053_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	053	0		29	10	S5921_053_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	053	0		29	10	S5921_053_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	053	0		29	10	S5921_053_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	061	0		29	10	S5921_061_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	59.65	178.95								59.65						163.95			178.95		59.65
S5921	061	0		29	10	S5921_061_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	061	0		29	10	S5921_061_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	061	0		29	10	S5921_061_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	062	0		29	10	S5921_062_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	062	0		29	10	S5921_062_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	89.00	267.00								89.00						252.00			267.00		89.00
S5921	062	0		29	10	S5921_062_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	062	0		29	10	S5921_062_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	063	0		29	10	S5921_063_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	063	0		29	10	S5921_063_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	063	0		29	10	S5921_063_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	063	0		29	10	S5921_063_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	063	0		29	10	S5921_063_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	063	0		29	10	S5921_063_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	063	0		29	10	S5921_063_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	063	0		29	10	S5921_063_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	071	0		29	10	S5921_071_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	071	0		29	10	S5921_071_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	071	0		29	10	S5921_071_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	071	0		29	10	S5921_071_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	76.50	229.50								76.50						214.50			229.50		76.50
S5921	072	0		29	10	S5921_072_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	072	0		29	10	S5921_072_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	072	0		29	10	S5921_072_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	072	0		29	10	S5921_072_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	073	0		29	10	S5921_073_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	073	0		29	10	S5921_073_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	073	0		29	10	S5921_073_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	073	0		29	10	S5921_073_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	073	0		29	10	S5921_073_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	073	0		29	10	S5921_073_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	073	0		29	10	S5921_073_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	073	0		29	10	S5921_073_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	081	0		29	10	S5921_081_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	63.05	189.15								63.05						174.15			189.15		63.05
S5921	081	0		29	10	S5921_081_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	081	0		29	10	S5921_081_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	081	0		29	10	S5921_081_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	082	0		29	10	S5921_082_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	082	0		29	10	S5921_082_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	64.00	192.00								64.00						177.00			192.00		64.00
S5921	082	0		29	10	S5921_082_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	082	0		29	10	S5921_082_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	083	0		29	10	S5921_083_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	083	0		29	10	S5921_083_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	083	0		29	10	S5921_083_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	083	0		29	10	S5921_083_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	083	0		29	10	S5921_083_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	083	0		29	10	S5921_083_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	083	0		29	10	S5921_083_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	083	0		29	10	S5921_083_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	091	0		29	10	S5921_091_0	3	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	60.05	180.15								60.05						165.15			180.15		60.05
S5921	091	0		29	10	S5921_091_0	3	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	091	0		29	10	S5921_091_0	3	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	091	0		29	10	S5921_091_0	3	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	092	0		29	10	S5921_092_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	092	0		29	10	S5921_092_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	092	0		29	10	S5921_092_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	092	0		29	10	S5921_092_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	093	0		29	10	S5921_093_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	093	0		29	10	S5921_093_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	093	0		29	10	S5921_093_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	093	0		29	10	S5921_093_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	093	0		29	10	S5921_093_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	093	0		29	10	S5921_093_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	093	0		29	10	S5921_093_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	093	0		29	10	S5921_093_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	101	0		29	10	S5921_101_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	62.00	186.00								62.00						171.00			186.00		62.00
S5921	101	0		29	10	S5921_101_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	101	0		29	10	S5921_101_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	101	0		29	10	S5921_101_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	102	0		29	10	S5921_102_0	4	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	97.00	291.00								97.00						276.00			291.00		97.00
S5921	102	0		29	10	S5921_102_0	4	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	102	0		29	10	S5921_102_0	4	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	102	0		29	10	S5921_102_0	4	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	103	0		29	10	S5921_103_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	103	0		29	10	S5921_103_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	103	0		29	10	S5921_103_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	103	0		29	10	S5921_103_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	103	0		29	10	S5921_103_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	103	0		29	10	S5921_103_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	103	0		29	10	S5921_103_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	103	0		29	10	S5921_103_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	111	0		29	10	S5921_111_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	111	0		29	10	S5921_111_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	111	0		29	10	S5921_111_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	111	0		29	10	S5921_111_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	60.30	180.90								60.30						165.90			180.90		60.30
S5921	112	0		29	10	S5921_112_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	112	0		29	10	S5921_112_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	89.00	267.00								89.00						252.00			267.00		89.00
S5921	112	0		29	10	S5921_112_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	112	0		29	10	S5921_112_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	113	0		29	10	S5921_113_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	113	0		29	10	S5921_113_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	113	0		29	10	S5921_113_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	113	0		29	10	S5921_113_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	113	0		29	10	S5921_113_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	113	0		29	10	S5921_113_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	113	0		29	10	S5921_113_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	113	0		29	10	S5921_113_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	121	0		29	10	S5921_121_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	63.70	191.10								63.70						176.10			191.10		63.70
S5921	121	0		29	10	S5921_121_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	121	0		29	10	S5921_121_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	121	0		29	10	S5921_121_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	122	0		29	10	S5921_122_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	122	0		29	10	S5921_122_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	122	0		29	10	S5921_122_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	122	0		29	10	S5921_122_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	123	0		29	10	S5921_123_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	123	0		29	10	S5921_123_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	123	0		29	10	S5921_123_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	123	0		29	10	S5921_123_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	123	0		29	10	S5921_123_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	123	0		29	10	S5921_123_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	123	0		29	10	S5921_123_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	123	0		29	10	S5921_123_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	131	0		29	10	S5921_131_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	58.45	175.35								58.45						160.35			175.35		58.45
S5921	131	0		29	10	S5921_131_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	131	0		29	10	S5921_131_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	131	0		29	10	S5921_131_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	132	0		29	10	S5921_132_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	92.00	276.00								92.00						261.00			276.00		92.00
S5921	132	0		29	10	S5921_132_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	132	0		29	10	S5921_132_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	132	0		29	10	S5921_132_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	133	0		29	10	S5921_133_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	133	0		29	10	S5921_133_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	133	0		29	10	S5921_133_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	133	0		29	10	S5921_133_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	133	0		29	10	S5921_133_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	133	0		29	10	S5921_133_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	133	0		29	10	S5921_133_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	133	0		29	10	S5921_133_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	141	0		29	10	S5921_141_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	54.30	162.90								54.30						147.90			162.90		54.30
S5921	141	0		29	10	S5921_141_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	141	0		29	10	S5921_141_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	141	0		29	10	S5921_141_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	142	0		29	10	S5921_142_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	142	0		29	10	S5921_142_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	142	0		29	10	S5921_142_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	142	0		29	10	S5921_142_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	143	0		29	10	S5921_143_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	143	0		29	10	S5921_143_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	143	0		29	10	S5921_143_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	143	0		29	10	S5921_143_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	143	0		29	10	S5921_143_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	143	0		29	10	S5921_143_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	143	0		29	10	S5921_143_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	143	0		29	10	S5921_143_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	151	0		29	10	S5921_151_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	151	0		29	10	S5921_151_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	51.85	155.55								51.85						140.55			155.55		51.85
S5921	151	0		29	10	S5921_151_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	151	0		29	10	S5921_151_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	152	0		29	10	S5921_152_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	91.00	273.00								91.00						258.00			273.00		91.00
S5921	152	0		29	10	S5921_152_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	152	0		29	10	S5921_152_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	152	0		29	10	S5921_152_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	153	0		29	10	S5921_153_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	153	0		29	10	S5921_153_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	153	0		29	10	S5921_153_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	153	0		29	10	S5921_153_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	153	0		29	10	S5921_153_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	153	0		29	10	S5921_153_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	153	0		29	10	S5921_153_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	153	0		29	10	S5921_153_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	161	0		29	10	S5921_161_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	161	0		29	10	S5921_161_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	161	0		29	10	S5921_161_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	161	0		29	10	S5921_161_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	66.95	200.85								66.95						185.85			200.85		66.95
S5921	162	0		29	10	S5921_162_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	162	0		29	10	S5921_162_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	162	0		29	10	S5921_162_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	162	0		29	10	S5921_162_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	163	0		29	10	S5921_163_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	163	0		29	10	S5921_163_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	163	0		29	10	S5921_163_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	163	0		29	10	S5921_163_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	163	0		29	10	S5921_163_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	163	0		29	10	S5921_163_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	163	0		29	10	S5921_163_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	163	0		29	10	S5921_163_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	171	0		29	10	S5921_171_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	171	0		29	10	S5921_171_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	59.65	178.95								59.65						163.95			178.95		59.65
S5921	171	0		29	10	S5921_171_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	171	0		29	10	S5921_171_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	172	0		29	10	S5921_172_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	172	0		29	10	S5921_172_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	172	0		29	10	S5921_172_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	172	0		29	10	S5921_172_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	173	0		29	10	S5921_173_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	173	0		29	10	S5921_173_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	173	0		29	10	S5921_173_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	173	0		29	10	S5921_173_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	173	0		29	10	S5921_173_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	173	0		29	10	S5921_173_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	173	0		29	10	S5921_173_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	173	0		29	10	S5921_173_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	181	0		29	10	S5921_181_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	181	0		29	10	S5921_181_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	181	0		29	10	S5921_181_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	63.55	190.65								63.55						175.65			190.65		63.55
S5921	181	0		29	10	S5921_181_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	182	0		29	10	S5921_182_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	182	0		29	10	S5921_182_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	182	0		29	10	S5921_182_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	182	0		29	10	S5921_182_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	183	0		29	10	S5921_183_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	183	0		29	10	S5921_183_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	183	0		29	10	S5921_183_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	183	0		29	10	S5921_183_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	183	0		29	10	S5921_183_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	183	0		29	10	S5921_183_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	183	0		29	10	S5921_183_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	183	0		29	10	S5921_183_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	191	0		29	10	S5921_191_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	191	0		29	10	S5921_191_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	191	0		29	10	S5921_191_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	191	0		29	10	S5921_191_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	57.20	171.60								57.20						156.60			171.60		57.20
S5921	192	0		29	10	S5921_192_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	192	0		29	10	S5921_192_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	192	0		29	10	S5921_192_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	96.00	288.00								96.00						273.00			288.00		96.00
S5921	192	0		29	10	S5921_192_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	193	0		29	10	S5921_193_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	193	0		29	10	S5921_193_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	193	0		29	10	S5921_193_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	193	0		29	10	S5921_193_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	193	0		29	10	S5921_193_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	193	0		29	10	S5921_193_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	193	0		29	10	S5921_193_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	193	0		29	10	S5921_193_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	201	0		29	10	S5921_201_0	4	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	201	0		29	10	S5921_201_0	4	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	201	0		29	10	S5921_201_0	4	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	58.60	175.80								58.60						160.80			175.80		58.60
S5921	201	0		29	10	S5921_201_0	4	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	202	0		29	10	S5921_202_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	202	0		29	10	S5921_202_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	91.00	273.00								91.00						258.00			273.00		91.00
S5921	202	0		29	10	S5921_202_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	202	0		29	10	S5921_202_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	203	0		29	10	S5921_203_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	55.80	167.40								55.80						152.40			167.40		55.80
S5921	203	0		29	10	S5921_203_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	203	0		29	10	S5921_203_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	203	0		29	10	S5921_203_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	207	0		29	10	S5921_207_0	4	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	207	0		29	10	S5921_207_0	4	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	207	0		29	10	S5921_207_0	4	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	207	0		29	10	S5921_207_0	4	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	213	0		29	10	S5921_213_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	213	0		29	10	S5921_213_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	213	0		29	10	S5921_213_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	213	0		29	10	S5921_213_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	213	0		29	10	S5921_213_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	213	0		29	10	S5921_213_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	213	0		29	10	S5921_213_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	213	0		29	10	S5921_213_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	221	0		29	10	S5921_221_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	68.10	204.30								68.10						189.30			204.30		68.10
S5921	221	0		29	10	S5921_221_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	221	0		29	10	S5921_221_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	221	0		29	10	S5921_221_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	222	0		29	10	S5921_222_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	97.00	291.00								97.00						276.00			291.00		97.00
S5921	222	0		29	10	S5921_222_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	222	0		29	10	S5921_222_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	222	0		29	10	S5921_222_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	223	0		29	10	S5921_223_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	223	0		29	10	S5921_223_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	223	0		29	10	S5921_223_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	223	0		29	10	S5921_223_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	223	0		29	10	S5921_223_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	223	0		29	10	S5921_223_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	223	0		29	10	S5921_223_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	223	0		29	10	S5921_223_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	231	0		29	10	S5921_231_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	231	0		29	10	S5921_231_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	231	0		29	10	S5921_231_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	50.25	150.75								50.25						135.75			150.75		50.25
S5921	231	0		29	10	S5921_231_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	232	0		29	10	S5921_232_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	232	0		29	10	S5921_232_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	232	0		29	10	S5921_232_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	232	0		29	10	S5921_232_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	233	0		29	10	S5921_233_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	233	0		29	10	S5921_233_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	233	0		29	10	S5921_233_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	233	0		29	10	S5921_233_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	233	0		29	10	S5921_233_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	233	0		29	10	S5921_233_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	233	0		29	10	S5921_233_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	233	0		29	10	S5921_233_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	235	0		29	10	S5921_235_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	235	0		29	10	S5921_235_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	235	0		29	10	S5921_235_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	235	0		29	10	S5921_235_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	235	0		29	10	S5921_235_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	235	0		29	10	S5921_235_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	235	0		29	10	S5921_235_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	235	0		29	10	S5921_235_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	237	0		29	10	S5921_237_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	65.45	196.35								65.45						181.35			196.35		65.45
S5921	237	0		29	10	S5921_237_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	237	0		29	10	S5921_237_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	237	0		29	10	S5921_237_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	238	0		29	10	S5921_238_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	238	0		29	10	S5921_238_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	238	0		29	10	S5921_238_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	238	0		29	10	S5921_238_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	239	0		29	10	S5921_239_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	239	0		29	10	S5921_239_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	239	0		29	10	S5921_239_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	239	0		29	10	S5921_239_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	239	0		29	10	S5921_239_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	239	0		29	10	S5921_239_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	239	0		29	10	S5921_239_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	239	0		29	10	S5921_239_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	247	0		29	10	S5921_247_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	247	0		29	10	S5921_247_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	247	0		29	10	S5921_247_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	71.55	214.65								71.55						199.65			214.65		71.55
S5921	247	0		29	10	S5921_247_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	248	0		29	10	S5921_248_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	78.00	234.00								78.00						219.00			234.00		78.00
S5921	248	0		29	10	S5921_248_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	248	0		29	10	S5921_248_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	248	0		29	10	S5921_248_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	249	0		29	10	S5921_249_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	249	0		29	10	S5921_249_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	249	0		29	10	S5921_249_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	249	0		29	10	S5921_249_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	249	0		29	10	S5921_249_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	249	0		29	10	S5921_249_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	249	0		29	10	S5921_249_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	249	0		29	10	S5921_249_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	261	0		29	10	S5921_261_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	261	0		29	10	S5921_261_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	261	0		29	10	S5921_261_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	49.00	147.00								49.00						132.00			147.00		49.00
S5921	261	0		29	10	S5921_261_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	262	0		29	10	S5921_262_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	262	0		29	10	S5921_262_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	262	0		29	10	S5921_262_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	262	0		29	10	S5921_262_0	3	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	263	0		29	10	S5921_263_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	263	0		29	10	S5921_263_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	263	0		29	10	S5921_263_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	263	0		29	10	S5921_263_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	263	0		29	10	S5921_263_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	263	0		29	10	S5921_263_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	263	0		29	10	S5921_263_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	263	0		29	10	S5921_263_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	265	0		29	10	S5921_265_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	265	0		29	10	S5921_265_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	56.10	168.30								56.10						153.30			168.30		56.10
S5921	265	0		29	10	S5921_265_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	265	0		29	10	S5921_265_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	266	0		29	10	S5921_266_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	266	0		29	10	S5921_266_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	266	0		29	10	S5921_266_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	266	0		29	10	S5921_266_0	3	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	273	0		29	10	S5921_273_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	273	0		29	10	S5921_273_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	273	0		29	10	S5921_273_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	273	0		29	10	S5921_273_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	273	0		29	10	S5921_273_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	273	0		29	10	S5921_273_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	273	0		29	10	S5921_273_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	273	0		29	10	S5921_273_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	281	0		29	10	S5921_281_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	281	0		29	10	S5921_281_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	281	0		29	10	S5921_281_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	60.65	181.95								60.65						166.95			181.95		60.65
S5921	281	0		29	10	S5921_281_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	282	0		29	10	S5921_282_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	282	0		29	10	S5921_282_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	88.00	264.00								88.00						249.00			264.00		88.00
S5921	282	0		29	10	S5921_282_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	282	0		29	10	S5921_282_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	283	0		29	10	S5921_283_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	283	0		29	10	S5921_283_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	283	0		29	10	S5921_283_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	283	0		29	10	S5921_283_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	283	0		29	10	S5921_283_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	283	0		29	10	S5921_283_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	283	0		29	10	S5921_283_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	283	0		29	10	S5921_283_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	286	0		29	10	S5921_286_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	286	0		29	10	S5921_286_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	61.25	183.75								61.25						168.75			183.75		61.25
S5921	286	0		29	10	S5921_286_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	286	0		29	10	S5921_286_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	288	0		29	10	S5921_288_0	3	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	288	0		29	10	S5921_288_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	288	0		29	10	S5921_288_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	288	0		29	10	S5921_288_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	293	0		29	10	S5921_293_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	293	0		29	10	S5921_293_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	293	0		29	10	S5921_293_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	293	0		29	10	S5921_293_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	293	0		29	10	S5921_293_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	293	0		29	10	S5921_293_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	293	0		29	10	S5921_293_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	293	0		29	10	S5921_293_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	301	0		29	10	S5921_301_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	56.95	170.85								56.95						155.85			170.85		56.95
S5921	301	0		29	10	S5921_301_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	301	0		29	10	S5921_301_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	301	0		29	10	S5921_301_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	302	0		29	10	S5921_302_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	91.00	273.00								91.00						258.00			273.00		91.00
S5921	302	0		29	10	S5921_302_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	302	0		29	10	S5921_302_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	302	0		29	10	S5921_302_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	303	0		29	10	S5921_303_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	303	0		29	10	S5921_303_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	303	0		29	10	S5921_303_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	303	0		29	10	S5921_303_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	303	0		29	10	S5921_303_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	303	0		29	10	S5921_303_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	303	0		29	10	S5921_303_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	303	0		29	10	S5921_303_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	311	0		29	10	S5921_311_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	56.30	168.90								56.30						153.90			168.90		56.30
S5921	311	0		29	10	S5921_311_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	311	0		29	10	S5921_311_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	311	0		29	10	S5921_311_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	312	0		29	10	S5921_312_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	98.00	294.00								98.00						279.00			294.00		98.00
S5921	312	0		29	10	S5921_312_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	312	0		29	10	S5921_312_0	3	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	312	0		29	10	S5921_312_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	313	0		29	10	S5921_313_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	313	0		29	10	S5921_313_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	313	0		29	10	S5921_313_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	95.00	285.00								95.00						270.00			285.00		95.00
S5921	313	0		29	10	S5921_313_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	313	0		29	10	S5921_313_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	313	0		29	10	S5921_313_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	313	0		29	10	S5921_313_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	313	0		29	10	S5921_313_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	321	0		29	10	S5921_321_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	53.40	160.20								53.40						145.20			160.20		53.40
S5921	321	0		29	10	S5921_321_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	321	0		29	10	S5921_321_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	321	0		29	10	S5921_321_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	322	0		29	10	S5921_322_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	322	0		29	10	S5921_322_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	83.00	249.00								83.00						234.00			249.00		83.00
S5921	322	0		29	10	S5921_322_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	322	0		29	10	S5921_322_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	323	0		29	10	S5921_323_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	85.00	255.00								85.00						240.00			255.00		85.00
S5921	323	0		29	10	S5921_323_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	323	0		29	10	S5921_323_0	2	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	323	0		29	10	S5921_323_0	2	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	323	0		29	10	S5921_323_0	2	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	323	0		29	10	S5921_323_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	323	0		29	10	S5921_323_0	2	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	323	0		29	10	S5921_323_0	2	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	331	0		29	10	S5921_331_0	2	3	2	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100		2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	49.45	148.35								49.45						133.35			148.35		49.45
S5921	331	0		29	10	S5921_331_0	2	2	2	1	Tier 2 - Generic and Preferred Brand	010001		2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	22.00	66.00								22.00						51.00			66.00		22.00
S5921	331	0		29	10	S5921_331_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00						0.00			15.00		5.00
S5921	331	0		29	10	S5921_331_0	2	4	2	1	Tier 4 - Specialty (Generic, Brand)	010010		1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	25	25								25						25			25		25	Tier 4 - Specialty (Generic, Brand)																					
S5921	332	0		29	10	S5921_332_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	86.00	258.00								86.00						243.00			258.00		86.00
S5921	332	0		29	10	S5921_332_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	332	0		29	10	S5921_332_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	332	0		29	10	S5921_332_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	333	0		29	10	S5921_333_0	3	1	4	1	Tier 1 - Preferred Generic	001000	1	2				Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	333	0		29	10	S5921_333_0	3	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	39.00	117.00								39.00						102.00			117.00		39.00
S5921	333	0		29	10	S5921_333_0	3	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	82.00	246.00								82.00						231.00			246.00		82.00
S5921	333	0		29	10	S5921_333_0	3	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	333	0		29	10	S5921_333_0	3	1	4	3	Tier 1 - Preferred Generic	001000	1	2	1		1	Tier 1 - Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1 - Preferred Generic	2	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	14.00	42.00								14.00						14.00			42.00		14.00
S5921	333	0		29	10	S5921_333_0	3	2	4	3	Tier 2 - Generic and Preferred Brand	010001	1	2	2			Tier 2 - Generic and Preferred Brand																							Tier 2 - Generic and Preferred Brand			Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand																					
S5921	333	0		29	10	S5921_333_0	3	3	4	3	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2	2			Tier 3 - Other Non Preferred (Generic, Brand)																							Tier 3 - Other Non Preferred (Generic, Brand)			Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)																					
S5921	333	0		29	10	S5921_333_0	3	4	4	3	Tier 4 - Specialty (Generic, Brand)	010010	1	1	2			Tier 4 - Specialty (Generic, Brand)																							Tier 4 - Specialty (Generic, Brand)			Tier 4 - Specialty (Generic, Brand)																						Tier 4 - Specialty (Generic, Brand)																					
S5921	343	0		29	10	S5921_343_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	343	0		29	10	S5921_343_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	343	0		29	10	S5921_343_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	343	0		29	10	S5921_343_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	344	0		29	10	S5921_344_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	344	0		29	10	S5921_344_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	344	0		29	10	S5921_344_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	344	0		29	10	S5921_344_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	345	0		29	10	S5921_345_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	345	0		29	10	S5921_345_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	345	0		29	10	S5921_345_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	93.00	279.00								93.00						264.00			279.00		93.00
S5921	345	0		29	10	S5921_345_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	346	0		29	10	S5921_346_0	4	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	346	0		29	10	S5921_346_0	4	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5921	346	0		29	10	S5921_346_0	4	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	90.00	270.00								90.00						255.00			270.00		90.00
S5921	346	0		29	10	S5921_346_0	4	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	347	0		29	10	S5921_347_0	2	1	4	1	Tier 1-Preferred Generic	001000	1	2				Tier 1-Preferred Generic	111000000010000010010	31	90								31					90			90			31	Tier 1-Preferred Generic	2	2	Tier 1-Preferred Generic																						Tier 1-Preferred Generic	7.00	21.00								7.00						0.00			21.00		7.00
S5921	347	0		29	10	S5921_347_0	2	2	4	1	Tier 2 - Generic and Preferred Brand	010001	1	2				Tier 2 - Generic and Preferred Brand	111000000010000010010	31	90								31					90			90			31	Tier 2 - Generic and Preferred Brand	2	2	Tier 2 - Generic and Preferred Brand																						Tier 2 - Generic and Preferred Brand	35.00	105.00								35.00						90.00			105.00		35.00
S5921	347	0		29	10	S5921_347_0	2	3	4	1	Tier 3 - Other Non Preferred (Generic, Brand)	100100	1	2				Tier 3 - Other Non Preferred (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 3 - Other Non Preferred (Generic, Brand)	2	2	Tier 3 - Other Non Preferred (Generic, Brand)																						Tier 3 - Other Non Preferred (Generic, Brand)	90.00	270.00								90.00						255.00			270.00		90.00
S5921	347	0		29	10	S5921_347_0	2	4	4	1	Tier 4 - Specialty (Generic, Brand)	010010	1	1				Tier 4 - Specialty (Generic, Brand)	111000000010000010010	31	90								31					90			90			31	Tier 4 - Specialty (Generic, Brand)	2	1	Tier 4 - Specialty (Generic, Brand)	33	33								33						30			33		33	Tier 4 - Specialty (Generic, Brand)																					
S5937	001	0		29	10	S5937_001_0	3	1	3	1	Generic	010000		2				Generic	111000000010110000000	34	90								34		34								90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00		8.00	24.00								8.00
S5937	001	0		29	10	S5937_001_0	3	4	3	1	Specialty	010010		1				Specialty	111000000010110000000	34	90								34		34								90	34	Specialty	2	1	Specialty	33	33								33		33	33								33	Specialty																					
S5937	001	0		29	10	S5937_001_0	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010110000000	34	90								34		34								90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	73.00	219.00								73.00		73.00	219.00								73.00
S5937	001	0		29	10	S5937_001_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010110000000	34	90								34		34								90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00		32.00	96.00								32.00
S5946	003	0		29	10	S5946_003_0	1	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	15.00								6.00			12.00								6.00
S5946	003	0		29	10	S5946_003_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00
S5946	003	0		29	10	S5946_003_0	1	3	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	72.00	180.00								72.00			144.00								72.00
S5946	003	0		29	10	S5946_003_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5946	004	0		29	10	S5946_004_0	1	1	4	1	Preferred Generic	001000	1	2				Preferred Generic	111000000010010000000	34	90								34										90	34	Preferred Generic	2	2	Preferred Generic																						Preferred Generic	6.00	15.00								6.00			12.00								6.00
S5946	004	0		29	10	S5946_004_0	1	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00
S5946	004	0		29	10	S5946_004_0	1	3	4	1	Brand	000010	1	2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	72.00	180.00								72.00			144.00								72.00
S5946	004	0		29	10	S5946_004_0	1	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5953	001	0		29	10	S5953_001_0	2	1	3	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
S5953	001	0		29	10	S5953_001_0	2	3	3	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5953	001	0		29	10	S5953_001_0	2	2	3	1	Brand	000010		2				Brand	111000000010010000000	34	90								34										90	34	Brand	2	2	Brand																						Brand	41.00	123.00								41.00			82.00								41.00
S5953	002	0		29	10	S5953_002_0	2	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5953	002	0		29	10	S5953_002_0	2	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
S5953	002	0		29	10	S5953_002_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5953	002	0		29	10	S5953_002_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5953	002	0		29	10	S5953_002_0	2	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5953	002	0		29	10	S5953_002_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			76.00								38.00
S5953	002	0		29	10	S5953_002_0	2	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	8.00	24.00								8.00			16.00								8.00
S5953	002	0		29	10	S5953_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00
S5954	004	0		29	10	S5954_004_0	2	3	2	1	Tier 3	010010		1				Tier 3	111000000001010000000	30	90									10									90	31	Tier 3	2	1	Tier 3	25	25									25		25								25	Tier 3																					
S5954	004	0		29	10	S5954_004_0	2	2	2	1	Tier 2	000010		2				Tier 2	111000000001010000000	30	90									10									90	31	Tier 2	2	2	Tier 2																						Tier 2	40.00	80.00									40.00		80.00								40.00
S5954	004	0		29	10	S5954_004_0	2	1	2	1	Tier 1	010000		2				Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	4.00	8.00									4.00		8.00								4.00
S5954	005	0		29	10	S5954_005_0	4	3	4	1	Tier 3	100100	1	2				Tier 3	111000000001010000000	30	90									10									90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	140.00									70.00		140.00								70.00
S5954	005	0		29	10	S5954_005_0	4	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001010000000	30	90									10									90	31	Tier 4	2	1	Tier 4	33	33									33		33								33	Tier 4																					
S5954	005	0		29	10	S5954_005_0	4	1	4	1	Tier 1	001001	1	2				Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	6.00									3.00		6.00								3.00
S5954	005	0		29	10	S5954_005_0	4	4	4	3	Tier 4	010010	1	1	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S5954	005	0		29	10	S5954_005_0	4	1	4	3	Tier 1	001001	1	2	1		1	Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	3.00	6.00									3.00		6.00								3.00
S5954	005	0		29	10	S5954_005_0	4	2	4	1	Tier 2	001001	1	2				Tier 2	111000000001010000000	30	90									10									90	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	70.00									35.00		70.00								35.00
S5954	005	0		29	10	S5954_005_0	4	2	4	3	Tier 2	001001	1	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S5954	005	0		29	10	S5954_005_0	4	3	4	3	Tier 3	100100	1	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S5954	007	0		29	10	S5954_007_0	3	4	4	1	Tier 4	010010	1	1				Tier 4	111000000001010000000	30	90									10									90	31	Tier 4	2	1	Tier 4	33	33									33		33								33	Tier 4																					
S5954	007	0		29	10	S5954_007_0	3	3	4	1	Tier 3	100100	1	2				Tier 3	111000000001010000000	30	90									10									90	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	156.00									78.00		156.00								78.00
S5954	007	0		29	10	S5954_007_0	3	1	4	1	Tier 1	001001	1	2				Tier 1	111000000001010000000	30	90									10									90	31	Tier 1	2	2	Tier 1																						Tier 1	4.00	8.00									4.00		8.00								4.00
S5954	007	0		29	10	S5954_007_0	3	2	4	1	Tier 2	001001	1	2				Tier 2	111000000001010000000	30	90									10									90	31	Tier 2	2	2	Tier 2																						Tier 2	28.00	56.00									28.00		56.00								28.00
S5960	003	0		29	10	S5960_003_0	3	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	003	0		29	10	S5960_003_0	3	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	45.00	135.00								45.00						112.50			135.00		45.00
S5960	003	0		29	10	S5960_003_0	3	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	003	0		29	10	S5960_003_0	3	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	003	0		29	10	S5960_003_0	3	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.50	28.50								9.50						14.25			28.50		9.50
S5960	004	0		29	10	S5960_004_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	004	0		29	10	S5960_004_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	004	0		29	10	S5960_004_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	004	0		29	10	S5960_004_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	004	0		29	10	S5960_004_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	46.50	139.50								46.50						116.25			139.50		46.50
S5960	005	0		29	10	S5960_005_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	005	0		29	10	S5960_005_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	005	0		29	10	S5960_005_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	005	0		29	10	S5960_005_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	005	0		29	10	S5960_005_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	47.00	141.00								47.00						117.50			141.00		47.00
S5960	006	0		29	10	S5960_006_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	006	0		29	10	S5960_006_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	006	0		29	10	S5960_006_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	006	0		29	10	S5960_006_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	006	0		29	10	S5960_006_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.50	121.50								40.50						101.25			121.50		40.50
S5960	008	0		29	10	S5960_008_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.50	127.50								42.50						106.25			127.50		42.50
S5960	008	0		29	10	S5960_008_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	008	0		29	10	S5960_008_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	008	0		29	10	S5960_008_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	008	0		29	10	S5960_008_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.50	25.50								8.50						12.75			25.50		8.50
S5960	009	0		29	10	S5960_009_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	009	0		29	10	S5960_009_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	009	0		29	10	S5960_009_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	009	0		29	10	S5960_009_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00						12.00			24.00		8.00
S5960	009	0		29	10	S5960_009_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.00	132.00								44.00						110.00			132.00		44.00
S5960	011	0		29	10	S5960_011_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00								41.00						102.50			123.00		41.00
S5960	011	0		29	10	S5960_011_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5960	011	0		29	10	S5960_011_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	011	0		29	10	S5960_011_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	011	0		29	10	S5960_011_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	012	0		29	10	S5960_012_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00						12.00			24.00		8.00
S5960	012	0		29	10	S5960_012_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.50	127.50								42.50						106.25			127.50		42.50
S5960	012	0		29	10	S5960_012_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	012	0		29	10	S5960_012_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	012	0		29	10	S5960_012_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	013	0		29	10	S5960_013_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	46.00	138.00								46.00						115.00			138.00		46.00
S5960	013	0		29	10	S5960_013_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	013	0		29	10	S5960_013_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	013	0		29	10	S5960_013_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	013	0		29	10	S5960_013_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	017	0		29	10	S5960_017_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.50	25.50								8.50						12.75			25.50		8.50
S5960	017	0		29	10	S5960_017_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.50	133.50								44.50						111.25			133.50		44.50
S5960	017	0		29	10	S5960_017_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	017	0		29	10	S5960_017_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	017	0		29	10	S5960_017_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	019	0		29	10	S5960_019_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00						12.00			24.00		8.00
S5960	019	0		29	10	S5960_019_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.50	118.50								39.50						98.75			118.50		39.50
S5960	019	0		29	10	S5960_019_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	019	0		29	10	S5960_019_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	019	0		29	10	S5960_019_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	020	0		29	10	S5960_020_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00
S5960	020	0		29	10	S5960_020_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.50	22.50								7.50						11.25			22.50		7.50
S5960	020	0		29	10	S5960_020_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	020	0		29	10	S5960_020_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	020	0		29	10	S5960_020_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	021	0		29	10	S5960_021_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00								41.00						102.50			123.00		41.00
S5960	021	0		29	10	S5960_021_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00								8.00						12.00			24.00		8.00
S5960	021	0		29	10	S5960_021_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	021	0		29	10	S5960_021_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	021	0		29	10	S5960_021_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	022	0		29	10	S5960_022_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	022	0		29	10	S5960_022_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00								42.00						105.00			126.00		42.00
S5960	022	0		29	10	S5960_022_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	022	0		29	10	S5960_022_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	022	0		29	10	S5960_022_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	023	0		29	10	S5960_023_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	023	0		29	10	S5960_023_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00								41.00						102.50			123.00		41.00
S5960	023	0		29	10	S5960_023_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	023	0		29	10	S5960_023_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	023	0		29	10	S5960_023_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	025	0		29	10	S5960_025_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	025	0		29	10	S5960_025_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.50	124.50								41.50						103.75			124.50		41.50
S5960	025	0		29	10	S5960_025_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	025	0		29	10	S5960_025_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	025	0		29	10	S5960_025_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	026	0		29	10	S5960_026_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.50	133.50								44.50						111.25			133.50		44.50
S5960	026	0		29	10	S5960_026_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.00	27.00								9.00						13.50			27.00		9.00
S5960	026	0		29	10	S5960_026_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	026	0		29	10	S5960_026_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	026	0		29	10	S5960_026_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	028	0		29	10	S5960_028_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.50	28.50								9.50						14.25			28.50		9.50
S5960	028	0		29	10	S5960_028_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.50	121.50								40.50						101.25			121.50		40.50
S5960	028	0		29	10	S5960_028_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	028	0		29	10	S5960_028_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	028	0		29	10	S5960_028_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	030	0		29	10	S5960_030_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00								42.00						105.00			126.00		42.00
S5960	030	0		29	10	S5960_030_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	030	0		29	10	S5960_030_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	030	0		29	10	S5960_030_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	030	0		29	10	S5960_030_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	031	0		29	10	S5960_031_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	45.50	136.50								45.50						113.75			136.50		45.50
S5960	031	0		29	10	S5960_031_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.50	28.50								9.50						14.25			28.50		9.50
S5960	031	0		29	10	S5960_031_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	031	0		29	10	S5960_031_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	031	0		29	10	S5960_031_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	033	0		29	10	S5960_033_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	44.00	132.00								44.00						110.00			132.00		44.00
S5960	033	0		29	10	S5960_033_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	9.50	28.50								9.50						14.25			28.50		9.50
S5960	033	0		29	10	S5960_033_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	033	0		29	10	S5960_033_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5960	033	0		29	10	S5960_033_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	034	0		29	10	S5960_034_0	2	1	3	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010000010010	30	90								30					90			90			34	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	10.00	30.00								10.00						15.00			30.00		10.00
S5960	034	0		29	10	S5960_034_0	2	2	3	1	Tier 2 Preferred Brand	000001		2				Tier 2 Preferred Brand	111000000010000010010	30	90								30					90			90			34	Tier 2 Preferred Brand	2	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.50	106.50								35.50						88.75			106.50		35.50
S5960	034	0		29	10	S5960_034_0	2	3	3	1	Tier 3 Non-Preferred Brand or Generic	100100		2				Tier 3 Non-Preferred Brand or Generic	111000000010000010010	30	90								30					90			90			34	Tier 3 Non-Preferred Brand or Generic	2	2	Tier 3 Non-Preferred Brand or Generic																						Tier 3 Non-Preferred Brand or Generic	85.00	255.00								85.00						212.50			255.00		85.00
S5960	034	0		29	10	S5960_034_0	2	4	3	1	Tier 4 Non-Specialty Injectable	010010		2				Tier 4 Non-Specialty Injectable	111000000010000010010	30	90								30					90			90			34	Tier 4 Non-Specialty Injectable	2	1	Tier 4 Non-Specialty Injectable	29	29								29						29			29		29	Tier 4 Non-Specialty Injectable																					
S5960	034	0		29	10	S5960_034_0	2	5	3	1	Tier 5 Specialty	010010		1				Tier 5 Specialty	110000000010000100100	30									30				30			30				34	Tier 5 Specialty	2	1	Tier 5 Specialty	29									29					29			29			29	Tier 5 Specialty																					
S5967	035	0		29	10	S5967_035_0	3	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	035	0		29	10	S5967_035_0	3	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	035	0		29	10	S5967_035_0	3	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	035	0		29	10	S5967_035_0	3	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	036	0		29	10	S5967_036_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	036	0		29	10	S5967_036_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	036	0		29	10	S5967_036_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	036	0		29	10	S5967_036_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	037	0		29	10	S5967_037_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	037	0		29	10	S5967_037_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	037	0		29	10	S5967_037_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	037	0		29	10	S5967_037_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	038	0		29	10	S5967_038_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	038	0		29	10	S5967_038_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	038	0		29	10	S5967_038_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	038	0		29	10	S5967_038_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	039	0		29	10	S5967_039_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	039	0		29	10	S5967_039_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	039	0		29	10	S5967_039_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	039	0		29	10	S5967_039_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	040	0		29	10	S5967_040_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	040	0		29	10	S5967_040_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	040	0		29	10	S5967_040_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	040	0		29	10	S5967_040_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	041	0		29	10	S5967_041_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	041	0		29	10	S5967_041_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	041	0		29	10	S5967_041_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	041	0		29	10	S5967_041_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	042	0		29	10	S5967_042_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	042	0		29	10	S5967_042_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	042	0		29	10	S5967_042_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	042	0		29	10	S5967_042_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	043	0		29	10	S5967_043_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	043	0		29	10	S5967_043_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	043	0		29	10	S5967_043_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	043	0		29	10	S5967_043_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	044	0		29	10	S5967_044_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	044	0		29	10	S5967_044_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	044	0		29	10	S5967_044_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	044	0		29	10	S5967_044_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	045	0		29	10	S5967_045_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	045	0		29	10	S5967_045_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	045	0		29	10	S5967_045_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	045	0		29	10	S5967_045_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	046	0		29	10	S5967_046_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	046	0		29	10	S5967_046_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	046	0		29	10	S5967_046_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	046	0		29	10	S5967_046_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	047	0		29	10	S5967_047_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	047	0		29	10	S5967_047_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	047	0		29	10	S5967_047_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	047	0		29	10	S5967_047_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	048	0		29	10	S5967_048_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	048	0		29	10	S5967_048_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	048	0		29	10	S5967_048_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	048	0		29	10	S5967_048_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	049	0		29	10	S5967_049_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	049	0		29	10	S5967_049_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	049	0		29	10	S5967_049_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	049	0		29	10	S5967_049_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	050	0		29	10	S5967_050_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	050	0		29	10	S5967_050_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	050	0		29	10	S5967_050_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	050	0		29	10	S5967_050_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	051	0		29	10	S5967_051_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	051	0		29	10	S5967_051_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	051	0		29	10	S5967_051_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	051	0		29	10	S5967_051_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	052	0		29	10	S5967_052_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	052	0		29	10	S5967_052_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	052	0		29	10	S5967_052_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	052	0		29	10	S5967_052_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	053	0		29	10	S5967_053_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	053	0		29	10	S5967_053_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	053	0		29	10	S5967_053_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	053	0		29	10	S5967_053_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	054	0		29	10	S5967_054_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	054	0		29	10	S5967_054_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	054	0		29	10	S5967_054_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	054	0		29	10	S5967_054_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	055	0		29	10	S5967_055_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	055	0		29	10	S5967_055_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	055	0		29	10	S5967_055_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	055	0		29	10	S5967_055_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	056	0		29	10	S5967_056_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	056	0		29	10	S5967_056_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	056	0		29	10	S5967_056_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	056	0		29	10	S5967_056_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	057	0		29	10	S5967_057_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	057	0		29	10	S5967_057_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	057	0		29	10	S5967_057_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	057	0		29	10	S5967_057_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	058	0		29	10	S5967_058_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	058	0		29	10	S5967_058_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	058	0		29	10	S5967_058_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	058	0		29	10	S5967_058_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	059	0		29	10	S5967_059_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	059	0		29	10	S5967_059_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	059	0		29	10	S5967_059_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	059	0		29	10	S5967_059_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	060	0		29	10	S5967_060_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	060	0		29	10	S5967_060_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	060	0		29	10	S5967_060_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	060	0		29	10	S5967_060_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	061	0		29	10	S5967_061_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	061	0		29	10	S5967_061_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	061	0		29	10	S5967_061_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	061	0		29	10	S5967_061_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	062	0		29	10	S5967_062_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	062	0		29	10	S5967_062_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	062	0		29	10	S5967_062_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	062	0		29	10	S5967_062_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	063	0		29	10	S5967_063_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	063	0		29	10	S5967_063_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	063	0		29	10	S5967_063_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	063	0		29	10	S5967_063_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	064	0		29	10	S5967_064_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	064	0		29	10	S5967_064_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	064	0		29	10	S5967_064_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	064	0		29	10	S5967_064_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	065	0		29	10	S5967_065_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	065	0		29	10	S5967_065_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	065	0		29	10	S5967_065_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	065	0		29	10	S5967_065_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	066	0		29	10	S5967_066_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	066	0		29	10	S5967_066_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	066	0		29	10	S5967_066_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	066	0		29	10	S5967_066_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	067	0		29	10	S5967_067_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	067	0		29	10	S5967_067_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	067	0		29	10	S5967_067_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	067	0		29	10	S5967_067_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	068	0		29	10	S5967_068_0	2	1	4	1	Tier 1	010000	1	2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	068	0		29	10	S5967_068_0	2	2	4	1	Tier 2	000001	1	2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	068	0		29	10	S5967_068_0	2	3	4	1	Tier 3	100000	1	2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	068	0		29	10	S5967_068_0	2	4	4	1	Tier 4	000010	1	1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	33	33								33			33								33	Tier 4																					
S5967	138	0		29	10	S5967_138_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	138	0		29	10	S5967_138_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	31.00	93.00								31.00			93.00								31.00
S5967	138	0		29	10	S5967_138_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	138	0		29	10	S5967_138_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
S5967	139	0		29	10	S5967_139_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	139	0		29	10	S5967_139_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
S5967	139	0		29	10	S5967_139_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	41.00	123.00								41.00			123.00								41.00
S5967	139	0		29	10	S5967_139_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	140	0		29	10	S5967_140_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00
S5967	140	0		29	10	S5967_140_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	140	0		29	10	S5967_140_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	91.00	273.00								91.00			273.00								91.00
S5967	140	0		29	10	S5967_140_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	141	0		29	10	S5967_141_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	141	0		29	10	S5967_141_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	92.00	276.00								92.00			276.00								92.00
S5967	141	0		29	10	S5967_141_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	41.00	123.00								41.00			123.00								41.00
S5967	141	0		29	10	S5967_141_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	142	0		29	10	S5967_142_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	142	0		29	10	S5967_142_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	142	0		29	10	S5967_142_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	142	0		29	10	S5967_142_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
S5967	143	0		29	10	S5967_143_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	143	0		29	10	S5967_143_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	31.00	93.00								31.00			93.00								31.00
S5967	143	0		29	10	S5967_143_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00
S5967	143	0		29	10	S5967_143_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	144	0		29	10	S5967_144_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00
S5967	144	0		29	10	S5967_144_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	144	0		29	10	S5967_144_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00
S5967	144	0		29	10	S5967_144_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	145	0		29	10	S5967_145_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00
S5967	145	0		29	10	S5967_145_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	145	0		29	10	S5967_145_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	145	0		29	10	S5967_145_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00
S5967	146	0		29	10	S5967_146_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	146	0		29	10	S5967_146_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	146	0		29	10	S5967_146_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00
S5967	146	0		29	10	S5967_146_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00
S5967	147	0		29	10	S5967_147_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	147	0		29	10	S5967_147_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	147	0		29	10	S5967_147_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	147	0		29	10	S5967_147_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
S5967	148	0		29	10	S5967_148_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	148	0		29	10	S5967_148_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00
S5967	148	0		29	10	S5967_148_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	148	0		29	10	S5967_148_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	149	0		29	10	S5967_149_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00
S5967	149	0		29	10	S5967_149_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	149	0		29	10	S5967_149_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	149	0		29	10	S5967_149_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	150	0		29	10	S5967_150_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	150	0		29	10	S5967_150_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00
S5967	150	0		29	10	S5967_150_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00
S5967	150	0		29	10	S5967_150_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	151	0		29	10	S5967_151_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	67.00	201.00								67.00			201.00								67.00
S5967	151	0		29	10	S5967_151_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	151	0		29	10	S5967_151_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	151	0		29	10	S5967_151_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	152	0		29	10	S5967_152_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	152	0		29	10	S5967_152_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	31.00	93.00								31.00			93.00								31.00
S5967	152	0		29	10	S5967_152_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	77.00	231.00								77.00			231.00								77.00
S5967	152	0		29	10	S5967_152_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	153	0		29	10	S5967_153_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	153	0		29	10	S5967_153_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
S5967	153	0		29	10	S5967_153_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	153	0		29	10	S5967_153_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
S5967	154	0		29	10	S5967_154_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	154	0		29	10	S5967_154_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	154	0		29	10	S5967_154_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
S5967	154	0		29	10	S5967_154_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	155	0		29	10	S5967_155_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	155	0		29	10	S5967_155_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	155	0		29	10	S5967_155_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
S5967	155	0		29	10	S5967_155_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	156	0		29	10	S5967_156_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	156	0		29	10	S5967_156_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00
S5967	156	0		29	10	S5967_156_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00								86.00			258.00								86.00
S5967	156	0		29	10	S5967_156_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	157	0		29	10	S5967_157_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	157	0		29	10	S5967_157_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
S5967	157	0		29	10	S5967_157_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	157	0		29	10	S5967_157_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00
S5967	158	0		29	10	S5967_158_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	158	0		29	10	S5967_158_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00
S5967	158	0		29	10	S5967_158_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	83.00	249.00								83.00			249.00								83.00
S5967	158	0		29	10	S5967_158_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	159	0		29	10	S5967_159_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	159	0		29	10	S5967_159_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	90.00	270.00								90.00			270.00								90.00
S5967	159	0		29	10	S5967_159_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00
S5967	159	0		29	10	S5967_159_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	160	0		29	10	S5967_160_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	160	0		29	10	S5967_160_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00
S5967	160	0		29	10	S5967_160_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	160	0		29	10	S5967_160_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	86.00	258.00								86.00			258.00								86.00
S5967	161	0		29	10	S5967_161_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	161	0		29	10	S5967_161_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
S5967	161	0		29	10	S5967_161_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
S5967	161	0		29	10	S5967_161_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	162	0		29	10	S5967_162_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00
S5967	162	0		29	10	S5967_162_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	162	0		29	10	S5967_162_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	162	0		29	10	S5967_162_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	163	0		29	10	S5967_163_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	163	0		29	10	S5967_163_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
S5967	163	0		29	10	S5967_163_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	88.00	264.00								88.00			264.00								88.00
S5967	163	0		29	10	S5967_163_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	164	0		29	10	S5967_164_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	164	0		29	10	S5967_164_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00
S5967	164	0		29	10	S5967_164_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	164	0		29	10	S5967_164_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00
S5967	165	0		29	10	S5967_165_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	165	0		29	10	S5967_165_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00
S5967	165	0		29	10	S5967_165_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	165	0		29	10	S5967_165_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	166	0		29	10	S5967_166_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	166	0		29	10	S5967_166_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00
S5967	166	0		29	10	S5967_166_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	166	0		29	10	S5967_166_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	167	0		29	10	S5967_167_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	167	0		29	10	S5967_167_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	167	0		29	10	S5967_167_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00
S5967	167	0		29	10	S5967_167_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	87.00	261.00								87.00			261.00								87.00
S5967	168	0		29	10	S5967_168_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	67.00	201.00								67.00			201.00								67.00
S5967	168	0		29	10	S5967_168_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	168	0		29	10	S5967_168_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	168	0		29	10	S5967_168_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	169	0		29	10	S5967_169_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	169	0		29	10	S5967_169_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	169	0		29	10	S5967_169_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00
S5967	169	0		29	10	S5967_169_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00
S5967	170	0		29	10	S5967_170_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	170	0		29	10	S5967_170_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00
S5967	170	0		29	10	S5967_170_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00
S5967	170	0		29	10	S5967_170_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5967	171	0		29	10	S5967_171_0	2	1	3	1	Tier 1	010000		2				Tier 1	111000000010010000000	31	93								31										93	31	Tier 1	2	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00
S5967	171	0		29	10	S5967_171_0	2	2	3	1	Tier 2	000001		2				Tier 2	111000000010010000000	31	93								31										93	31	Tier 2	2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00
S5967	171	0		29	10	S5967_171_0	2	3	3	1	Tier 3	100000		2				Tier 3	111000000010010000000	31	93								31										93	31	Tier 3	2	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00
S5967	171	0		29	10	S5967_171_0	2	4	3	1	Tier 4	000010		1				Tier 4	111000000010010000000	31	93								31										93	31	Tier 4	2	1	Tier 4	25	25								25			25								25	Tier 4																					
S5983	001	0		29	10	S5983_001_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5983	001	0		29	10	S5983_001_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5983	001	0		29	10	S5983_001_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5983	001	0		29	10	S5983_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5983	004	0		29	10	S5983_004_0	2	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	53	53								53			53								53	Non-Preferred Brand																					
S5983	004	0		29	10	S5983_004_0	2	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	1	Preferred Brand	23	23								23			23								23	Preferred Brand																					
S5983	004	0		29	10	S5983_004_0	2	1	2	1	Generic	010000		2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	1	Generic	23	23								23			23								23	Generic																					
S5983	004	0		29	10	S5983_004_0	2	4	2	1	Specialty	010010		1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5983	005	0		29	10	S5983_005_0	3	1	4	1	Generic	010000	1	2				Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5983	005	0		29	10	S5983_005_0	3	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	34	90								34										90	34	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00
S5983	005	0		29	10	S5983_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	34	90								34										90	34	Non-Preferred Brand	2	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																					
S5983	005	0		29	10	S5983_005_0	3	4	4	1	Specialty	010010	1	1				Specialty	111000000010010000000	34	90								34										90	34	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5983	005	0		29	10	S5983_005_0	3	1	4	3	Generic	010000	1	2	1		1	Generic	111000000010010000000	34	90								34										90	34	Generic	2	2	Generic																						Generic	6.00	12.00								6.00			6.00								6.00
S5983	005	0		29	10	S5983_005_0	3	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5983	005	0		29	10	S5983_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5983	005	0		29	10	S5983_005_0	3	4	4	3	Specialty	010010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5993	001	0		29	10	S5993_001_0	4	3	2	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5993	001	0		29	10	S5993_001_0	4	2	2	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00			111.00								37.00
S5993	001	0		29	10	S5993_001_0	4	1	2	1	Generic	010000		2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	7.00	21.00								7.00			21.00								7.00
S5993	001	0		29	10	S5993_001_0	4	4	2	1	Specialty	000010		1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	25	25								25			25								25	Specialty																					
S5993	003	0		29	10	S5993_003_0	2	1	4	3	Generic	001000	1	2	1		1	Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
S5993	003	0		29	10	S5993_003_0	2	2	4	3	Preferred Brand	000001	1	2	2			Preferred Brand																							Preferred Brand			Preferred Brand																						Preferred Brand																					
S5993	003	0		29	10	S5993_003_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2			Non-Preferred Brand																							Non-Preferred Brand			Non-Preferred Brand																						Non-Preferred Brand																					
S5993	003	0		29	10	S5993_003_0	2	4	4	1	Specialty	000010	1	1				Specialty	111000000010010000000	30	90								30										90	31	Specialty	2	1	Specialty	33	33								33			33								33	Specialty																					
S5993	003	0		29	10	S5993_003_0	2	3	4	1	Non-Preferred Brand	100000	1	2				Non-Preferred Brand	111000000010010000000	30	90								30										90	31	Non-Preferred Brand	2	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00
S5993	003	0		29	10	S5993_003_0	2	4	4	3	Specialty	000010	1	1	2			Specialty																							Specialty			Specialty																						Specialty																					
S5993	003	0		29	10	S5993_003_0	2	1	4	1	Generic	001000	1	2				Generic	111000000010010000000	30	90								30										90	31	Generic	2	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00
S5993	003	0		29	10	S5993_003_0	2	2	4	1	Preferred Brand	000001	1	2				Preferred Brand	111000000010010000000	30	90								30										90	31	Preferred Brand	2	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00			111.00								37.00
S7694	001	0		29	10	S7694_001_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	001	0		29	10	S7694_001_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	001	0		29	10	S7694_001_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	001	0		29	10	S7694_001_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	001	0		29	10	S7694_001_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	002	0		29	10	S7694_002_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	002	0		29	10	S7694_002_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	23.00	69.00								23.00			69.00								23.00
S7694	002	0		29	10	S7694_002_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	33.00	99.00								33.00			99.00								33.00
S7694	002	0		29	10	S7694_002_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	002	0		29	10	S7694_002_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	003	0		29	10	S7694_003_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	003	0		29	10	S7694_003_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	30.00	90.00								30.00			90.00								30.00
S7694	003	0		29	10	S7694_003_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	20.00	60.00								20.00			60.00								20.00
S7694	003	0		29	10	S7694_003_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	003	0		29	10	S7694_003_0	3	5	2	1	Tier 5 Specialty Drugs	011010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	004	0		29	10	S7694_004_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	004	0		29	10	S7694_004_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	33.00	99.00								33.00			99.00								33.00
S7694	004	0		29	10	S7694_004_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	23.00	69.00								23.00			69.00								23.00
S7694	004	0		29	10	S7694_004_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	004	0		29	10	S7694_004_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	005	0		29	10	S7694_005_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	33.00	99.00								33.00			99.00								33.00
S7694	005	0		29	10	S7694_005_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	005	0		29	10	S7694_005_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	23.00	69.00								23.00			69.00								23.00
S7694	005	0		29	10	S7694_005_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	005	0		29	10	S7694_005_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	006	0		29	10	S7694_006_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	006	0		29	10	S7694_006_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	006	0		29	10	S7694_006_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	006	0		29	10	S7694_006_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	006	0		29	10	S7694_006_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	007	0		29	10	S7694_007_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	007	0		29	10	S7694_007_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	007	0		29	10	S7694_007_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	007	0		29	10	S7694_007_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	007	0		29	10	S7694_007_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	008	0		29	10	S7694_008_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	008	0		29	10	S7694_008_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	008	0		29	10	S7694_008_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	008	0		29	10	S7694_008_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	008	0		29	10	S7694_008_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	009	0		29	10	S7694_009_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	009	0		29	10	S7694_009_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	009	0		29	10	S7694_009_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	009	0		29	10	S7694_009_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	009	0		29	10	S7694_009_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	010	0		29	10	S7694_010_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	010	0		29	10	S7694_010_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	010	0		29	10	S7694_010_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	010	0		29	10	S7694_010_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	010	0		29	10	S7694_010_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	011	0		29	10	S7694_011_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	20.00	60.00								20.00			60.00								20.00
S7694	011	0		29	10	S7694_011_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	011	0		29	10	S7694_011_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	011	0		29	10	S7694_011_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	30.00	90.00								30.00			90.00								30.00
S7694	011	0		29	10	S7694_011_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	012	0		29	10	S7694_012_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	012	0		29	10	S7694_012_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	012	0		29	10	S7694_012_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	012	0		29	10	S7694_012_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	012	0		29	10	S7694_012_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	013	0		29	10	S7694_013_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	013	0		29	10	S7694_013_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	013	0		29	10	S7694_013_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	013	0		29	10	S7694_013_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	013	0		29	10	S7694_013_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	014	0		29	10	S7694_014_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	014	0		29	10	S7694_014_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	014	0		29	10	S7694_014_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	014	0		29	10	S7694_014_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	014	0		29	10	S7694_014_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	015	0		29	10	S7694_015_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	015	0		29	10	S7694_015_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	015	0		29	10	S7694_015_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	015	0		29	10	S7694_015_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	015	0		29	10	S7694_015_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	016	0		29	10	S7694_016_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	016	0		29	10	S7694_016_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	016	0		29	10	S7694_016_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	016	0		29	10	S7694_016_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	016	0		29	10	S7694_016_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	017	0		29	10	S7694_017_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	017	0		29	10	S7694_017_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	017	0		29	10	S7694_017_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	017	0		29	10	S7694_017_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	017	0		29	10	S7694_017_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	018	0		29	10	S7694_018_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	018	0		29	10	S7694_018_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	018	0		29	10	S7694_018_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	018	0		29	10	S7694_018_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	018	0		29	10	S7694_018_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	019	0		29	10	S7694_019_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	019	0		29	10	S7694_019_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	019	0		29	10	S7694_019_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	019	0		29	10	S7694_019_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	019	0		29	10	S7694_019_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	020	0		29	10	S7694_020_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	020	0		29	10	S7694_020_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	020	0		29	10	S7694_020_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	020	0		29	10	S7694_020_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	020	0		29	10	S7694_020_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	021	0		29	10	S7694_021_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	021	0		29	10	S7694_021_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	021	0		29	10	S7694_021_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	021	0		29	10	S7694_021_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	021	0		29	10	S7694_021_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	022	0		29	10	S7694_022_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	24.00	72.00								24.00			72.00								24.00
S7694	022	0		29	10	S7694_022_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	022	0		29	10	S7694_022_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	022	0		29	10	S7694_022_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	34.00	102.00								34.00			102.00								34.00
S7694	022	0		29	10	S7694_022_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	023	0		29	10	S7694_023_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	023	0		29	10	S7694_023_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	023	0		29	10	S7694_023_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	023	0		29	10	S7694_023_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	023	0		29	10	S7694_023_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	024	0		29	10	S7694_024_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	19.00	57.00								19.00			57.00								19.00
S7694	024	0		29	10	S7694_024_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	024	0		29	10	S7694_024_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	024	0		29	10	S7694_024_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	29.00	87.00								29.00			87.00								29.00
S7694	024	0		29	10	S7694_024_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	025	0		29	10	S7694_025_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	025	0		29	10	S7694_025_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	025	0		29	10	S7694_025_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	20.00	60.00								20.00			60.00								20.00
S7694	025	0		29	10	S7694_025_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	30.00	90.00								30.00			90.00								30.00
S7694	025	0		29	10	S7694_025_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	026	0		29	10	S7694_026_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	026	0		29	10	S7694_026_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	026	0		29	10	S7694_026_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	30.00	90.00								30.00			90.00								30.00
S7694	026	0		29	10	S7694_026_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	20.00	60.00								20.00			60.00								20.00
S7694	026	0		29	10	S7694_026_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	027	0		29	10	S7694_027_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	027	0		29	10	S7694_027_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	30.00	90.00								30.00			90.00								30.00
S7694	027	0		29	10	S7694_027_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	027	0		29	10	S7694_027_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	027	0		29	10	S7694_027_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	20.00	60.00								20.00			60.00								20.00
S7694	028	0		29	10	S7694_028_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	028	0		29	10	S7694_028_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	028	0		29	10	S7694_028_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	028	0		29	10	S7694_028_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	028	0		29	10	S7694_028_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	029	0		29	10	S7694_029_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	029	0		29	10	S7694_029_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	32.00	96.00								32.00			96.00								32.00
S7694	029	0		29	10	S7694_029_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	22.00	66.00								22.00			66.00								22.00
S7694	029	0		29	10	S7694_029_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	029	0		29	10	S7694_029_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	030	0		29	10	S7694_030_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	030	0		29	10	S7694_030_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	030	0		29	10	S7694_030_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	030	0		29	10	S7694_030_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	030	0		29	10	S7694_030_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	031	0		29	10	S7694_031_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	031	0		29	10	S7694_031_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	031	0		29	10	S7694_031_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	031	0		29	10	S7694_031_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	031	0		29	10	S7694_031_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	032	0		29	10	S7694_032_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	21.00	63.00								21.00			63.00								21.00
S7694	032	0		29	10	S7694_032_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	032	0		29	10	S7694_032_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	31.00	93.00								31.00			93.00								31.00
S7694	032	0		29	10	S7694_032_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	032	0		29	10	S7694_032_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	033	0		29	10	S7694_033_0	3	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	38.00	114.00								38.00			114.00								38.00
S7694	033	0		29	10	S7694_033_0	3	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	033	0		29	10	S7694_033_0	3	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	28.00	84.00								28.00			84.00								28.00
S7694	033	0		29	10	S7694_033_0	3	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	033	0		29	10	S7694_033_0	3	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	034	0		29	10	S7694_034_0	4	1	2	1	Tier 1 Preferred Generic	001000		2				Tier 1 Preferred Generic	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generic	2	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00
S7694	034	0		29	10	S7694_034_0	4	2	2	1	Tier 2 Non Preferred Generics	000100		2				Tier 2 Non Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 2 Non Preferred Generics	2	2	Tier 2 Non Preferred Generics																						Tier 2 Non Preferred Generics	47.00	141.00								47.00			141.00								47.00
S7694	034	0		29	10	S7694_034_0	4	4	2	1	Tier 4 NonPreferred Brand	100000		2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	034	0		29	10	S7694_034_0	4	3	2	1	Tier 3 Preferred Brand	000001		2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	37.00	111.00								37.00			111.00								37.00
S7694	034	0		29	10	S7694_034_0	4	5	2	1	Tier 5 Specialty Drugs	010010		1				Tier 5 Specialty Drugs	110000000010100000000	30									30		30									31	Tier 5 Specialty Drugs	2	1	Tier 5 Specialty Drugs	25									25		25									25	Tier 5 Specialty Drugs																					
S7694	035	0		29	10	S7694_035_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	035	0		29	10	S7694_035_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	035	0		29	10	S7694_035_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	035	0		29	10	S7694_035_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	035	0		29	10	S7694_035_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	036	0		29	10	S7694_036_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	036	0		29	10	S7694_036_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	036	0		29	10	S7694_036_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	036	0		29	10	S7694_036_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	036	0		29	10	S7694_036_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	037	0		29	10	S7694_037_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	037	0		29	10	S7694_037_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	037	0		29	10	S7694_037_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	037	0		29	10	S7694_037_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	037	0		29	10	S7694_037_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	038	0		29	10	S7694_038_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	038	0		29	10	S7694_038_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	038	0		29	10	S7694_038_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	038	0		29	10	S7694_038_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	038	0		29	10	S7694_038_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	039	0		29	10	S7694_039_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	039	0		29	10	S7694_039_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	039	0		29	10	S7694_039_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	039	0		29	10	S7694_039_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	039	0		29	10	S7694_039_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	040	0		29	10	S7694_040_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	040	0		29	10	S7694_040_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	040	0		29	10	S7694_040_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	040	0		29	10	S7694_040_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	040	0		29	10	S7694_040_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	041	0		29	10	S7694_041_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	041	0		29	10	S7694_041_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	041	0		29	10	S7694_041_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	041	0		29	10	S7694_041_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	041	0		29	10	S7694_041_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	042	0		29	10	S7694_042_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	042	0		29	10	S7694_042_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	042	0		29	10	S7694_042_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	042	0		29	10	S7694_042_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	042	0		29	10	S7694_042_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	043	0		29	10	S7694_043_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	043	0		29	10	S7694_043_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	043	0		29	10	S7694_043_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	043	0		29	10	S7694_043_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	043	0		29	10	S7694_043_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	044	0		29	10	S7694_044_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	044	0		29	10	S7694_044_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	044	0		29	10	S7694_044_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	044	0		29	10	S7694_044_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	044	0		29	10	S7694_044_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	045	0		29	10	S7694_045_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	045	0		29	10	S7694_045_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	045	0		29	10	S7694_045_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	045	0		29	10	S7694_045_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	045	0		29	10	S7694_045_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	046	0		29	10	S7694_046_0	2	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	046	0		29	10	S7694_046_0	2	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	046	0		29	10	S7694_046_0	2	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	046	0		29	10	S7694_046_0	2	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	046	0		29	10	S7694_046_0	2	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	047	0		29	10	S7694_047_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	047	0		29	10	S7694_047_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	047	0		29	10	S7694_047_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	047	0		29	10	S7694_047_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	047	0		29	10	S7694_047_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	048	0		29	10	S7694_048_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	048	0		29	10	S7694_048_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	048	0		29	10	S7694_048_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	048	0		29	10	S7694_048_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	048	0		29	10	S7694_048_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	049	0		29	10	S7694_049_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	049	0		29	10	S7694_049_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	049	0		29	10	S7694_049_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	049	0		29	10	S7694_049_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	049	0		29	10	S7694_049_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	050	0		29	10	S7694_050_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	050	0		29	10	S7694_050_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	050	0		29	10	S7694_050_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	050	0		29	10	S7694_050_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	050	0		29	10	S7694_050_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	051	0		29	10	S7694_051_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	051	0		29	10	S7694_051_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	051	0		29	10	S7694_051_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	051	0		29	10	S7694_051_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	051	0		29	10	S7694_051_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	052	0		29	10	S7694_052_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	052	0		29	10	S7694_052_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	052	0		29	10	S7694_052_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	052	0		29	10	S7694_052_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	052	0		29	10	S7694_052_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	053	0		29	10	S7694_053_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	053	0		29	10	S7694_053_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	053	0		29	10	S7694_053_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	053	0		29	10	S7694_053_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	053	0		29	10	S7694_053_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	054	0		29	10	S7694_054_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	054	0		29	10	S7694_054_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	054	0		29	10	S7694_054_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	054	0		29	10	S7694_054_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	054	0		29	10	S7694_054_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	055	0		29	10	S7694_055_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	055	0		29	10	S7694_055_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	055	0		29	10	S7694_055_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	055	0		29	10	S7694_055_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	055	0		29	10	S7694_055_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	056	0		29	10	S7694_056_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	056	0		29	10	S7694_056_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	056	0		29	10	S7694_056_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	056	0		29	10	S7694_056_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	056	0		29	10	S7694_056_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	057	0		29	10	S7694_057_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	057	0		29	10	S7694_057_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	057	0		29	10	S7694_057_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	057	0		29	10	S7694_057_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	057	0		29	10	S7694_057_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	058	0		29	10	S7694_058_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	058	0		29	10	S7694_058_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	058	0		29	10	S7694_058_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	058	0		29	10	S7694_058_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	058	0		29	10	S7694_058_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	059	0		29	10	S7694_059_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	059	0		29	10	S7694_059_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	059	0		29	10	S7694_059_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	059	0		29	10	S7694_059_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	059	0		29	10	S7694_059_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	060	0		29	10	S7694_060_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	060	0		29	10	S7694_060_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	060	0		29	10	S7694_060_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	060	0		29	10	S7694_060_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	060	0		29	10	S7694_060_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	061	0		29	10	S7694_061_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	061	0		29	10	S7694_061_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	061	0		29	10	S7694_061_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	061	0		29	10	S7694_061_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	061	0		29	10	S7694_061_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	062	0		29	10	S7694_062_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	062	0		29	10	S7694_062_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	062	0		29	10	S7694_062_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	062	0		29	10	S7694_062_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	062	0		29	10	S7694_062_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	063	0		29	10	S7694_063_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	063	0		29	10	S7694_063_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	063	0		29	10	S7694_063_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	063	0		29	10	S7694_063_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	063	0		29	10	S7694_063_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	064	0		29	10	S7694_064_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	064	0		29	10	S7694_064_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	064	0		29	10	S7694_064_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	064	0		29	10	S7694_064_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	064	0		29	10	S7694_064_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	065	0		29	10	S7694_065_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	065	0		29	10	S7694_065_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	065	0		29	10	S7694_065_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	065	0		29	10	S7694_065_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	065	0		29	10	S7694_065_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	066	0		29	10	S7694_066_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	066	0		29	10	S7694_066_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	066	0		29	10	S7694_066_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	066	0		29	10	S7694_066_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	066	0		29	10	S7694_066_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	067	0		29	10	S7694_067_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	067	0		29	10	S7694_067_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	067	0		29	10	S7694_067_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	067	0		29	10	S7694_067_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S7694	067	0		29	10	S7694_067_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	068	0		29	10	S7694_068_0	3	1	4	1	Tier 1 Preferred Generics	001000	1	2				Tier 1 Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 Preferred Generics	2	2	Tier 1 Preferred Generics																						Tier 1 Preferred Generics	0.00	0.00								0.00			0.00								0.00
S7694	068	0		29	10	S7694_068_0	3	2	4	1	Tier 2 NonPreferred Generic	000100	1	2				Tier 2 NonPreferred Generic	111000000010010000000	30	90								30										90	31	Tier 2 NonPreferred Generic	2	2	Tier 2 NonPreferred Generic																						Tier 2 NonPreferred Generic	45.00	135.00								45.00			135.00								45.00
S7694	068	0		29	10	S7694_068_0	3	3	4	1	Tier 3 Preferred Brand	000001	1	2				Tier 3 Preferred Brand	111000000010010000000	30	90								30										90	31	Tier 3 Preferred Brand	2	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	40.00	120.00								40.00			120.00								40.00
S7694	068	0		29	10	S7694_068_0	3	4	4	1	Tier 4 NonPreferred Brand	100000	1	2				Tier 4 NonPreferred Brand	111000000010010000000	30	90								30										90	31	Tier 4 NonPreferred Brand	2	2	Tier 4 NonPreferred Brand																						Tier 4 NonPreferred Brand	75.00	225.00								75.00			225.00								75.00
S7694	068	0		29	10	S7694_068_0	3	5	4	1	Tier 5 Specialty	010010	1	1				Tier 5 Specialty	110000000010100000000	30									30		30									31	Tier 5 Specialty	2	1	Tier 5 Specialty	33									33		33									33	Tier 5 Specialty																					
S8067	001	0		29	10	S8067_001_0	5	2	4	1	Formulary Brand Drugs	000010	1	2				Formulary Brand Drugs	111000000010010000000	34	90								34										90	34	Formulary Brand Drugs	1	2	Formulary Brand Drugs																						Formulary Brand Drugs	50.00	125.00								50.00			125.00								50.00
S8067	001	0		29	10	S8067_001_0	5	3	4	1	Specialty Drugs	000010	1	1				Specialty Drugs	110000000010000000000	34									34											34	Specialty Drugs	2	1	Specialty Drugs	30									30											30	Specialty Drugs																					
S8067	001	0		29	10	S8067_001_0	5	1	4	1	Generic Drugs	010000	1	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	9.00	25.00								9.00			25.00								9.00
S8067	003	0		29	10	S8067_003_0	7	1	4	3	Generic Drugs	010000	3	2	1		1	Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
S8067	003	0		29	10	S8067_003_0	7	1	4	1	Generic Drugs	010000	3	2				Generic Drugs	111000000010010000000	34	90								34										90	34	Generic Drugs	2	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00
S8067	003	0		29	10	S8067_003_0	7	2	4	1	Preferred Brand Drugs	000001	3	2				Preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Preferred Brand Drugs	1	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	90.00								35.00			90.00								35.00
S8067	003	0		29	10	S8067_003_0	7	3	4	1	Non-preferred Brand Drugs	100000	3	2				Non-preferred Brand Drugs	111000000010010000000	34	90								34										90	34	Non-preferred Brand Drugs	1	2	Non-preferred Brand Drugs																						Non-preferred Brand Drugs	85.00	210.00								85.00			210.00								85.00
S8067	003	0		29	10	S8067_003_0	7	4	4	3	Specialty Drugs	000010	3	1	2			Specialty Drugs																							Specialty Drugs			Specialty Drugs																						Specialty Drugs																					
S8067	003	0		29	10	S8067_003_0	7	3	4	3	Non-preferred Brand Drugs	100000	3	2	2			Non-preferred Brand Drugs																							Non-preferred Brand Drugs			Non-preferred Brand Drugs																						Non-preferred Brand Drugs																					
S8067	003	0		29	10	S8067_003_0	7	2	4	3	Preferred Brand Drugs	000001	3	2	2			Preferred Brand Drugs																							Preferred Brand Drugs			Preferred Brand Drugs																						Preferred Brand Drugs																					
S8067	003	0		29	10	S8067_003_0	7	4	4	1	Specialty Drugs	000010	3	1				Specialty Drugs	110000000010100000000	34									34		34									34	Specialty Drugs	2	1	Specialty Drugs	30									30		30									30	Specialty Drugs																					
S8201	001	0		29	10	S8201_001_0	3	1	3	1	Generic	010000		2				Generic	111000000010010000000	31	90								31										90	31	Generic	2	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00
S8201	001	0		29	10	S8201_001_0	3	2	3	1	Preferred Brand	000001		2				Preferred Brand	111000000010010000000	31	90								31										90	31	Preferred Brand	1	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00
S8201	001	0		29	10	S8201_001_0	3	3	3	1	Non-Preferred Brand	100000		2				Non-Preferred Brand	111000000010010000000	31	90								31										90	31	Non-Preferred Brand	1	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00
S8201	001	0		29	10	S8201_001_0	3	4	3	1	Specialty	010010		1				Specialty	110000000010100000000	31									31		31									31	Specialty	2	1	Specialty	33									33		33									33	Specialty																					
S8465	001	0		29	10	S8465_001_0	2	5	2	1	Tier 5 - Specialty	100000		1				Tier 5 - Specialty	110000000010100000000	30									30		30									31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	25									25		25									25	Tier 5 - Specialty																					
S8465	001	0		29	10	S8465_001_0	2	4	2	1	Tier 4 - Brands	000010		2				Tier 4 - Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Brands	2	2	Tier 4 - Brands																						Tier 4 - Brands	70.00	210.00								70.00			210.00								70.00
S8465	001	0		29	10	S8465_001_0	2	3	2	1	Tier 3 - Preferred Brands	000001		2				Tier 3 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Preferred Brands	2	2	Tier 3 - Preferred Brands																						Tier 3 - Preferred Brands	25.00	75.00								25.00			75.00								25.00
S8465	001	0		29	10	S8465_001_0	2	1	2	1	Preferred Generics	001000		2				Preferred Generics	111000000010010000000	30	90								30										90	31	Preferred Generics	2	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00
S8465	001	0		29	10	S8465_001_0	2	2	2	1	Tier 2 - Generics	010000		2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
S8465	002	0		29	10	S8465_002_0	4	4	4	1	Tier 4 - Brands	000010	3	2				Tier 4 - Brands	111000000010010000000	30	90								30										90	31	Tier 4 - Brands	2	2	Tier 4 - Brands																						Tier 4 - Brands	65.00	195.00								65.00			195.00								65.00
S8465	002	0		29	10	S8465_002_0	4	3	4	1	Tier 3 - Preferred Brands	000001	1	2				Tier 3 - Preferred Brands	111000000010010000000	30	90								30										90	31	Tier 3 - Preferred Brands	2	2	Tier 3 - Preferred Brands																						Tier 3 - Preferred Brands	30.00	90.00								30.00			90.00								30.00
S8465	002	0		29	10	S8465_002_0	4	2	4	1	Tier 2 - Generics	010000	1	2				Tier 2 - Generics	111000000010010000000	30	90								30										90	31	Tier 2 - Generics	2	2	Tier 2 - Generics																						Tier 2 - Generics	5.00	15.00								5.00			15.00								5.00
S8465	002	0		29	10	S8465_002_0	4	1	4	1	Tier 1 - Preferred Generics	001000	3	2				Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
S8465	002	0		29	10	S8465_002_0	4	5	4	3	Tier 5 - Specialty	100000	1	1	2			Tier 5 - Specialty																							Tier 5 - Specialty			Tier 5 - Specialty																						Tier 5 - Specialty																					
S8465	002	0		29	10	S8465_002_0	4	1	4	3	Tier 1 - Preferred Generics	001000	3	2	1		1	Tier 1 - Preferred Generics	111000000010010000000	30	90								30										90	31	Tier 1 - Preferred Generics	2	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	0.00	0.00								0.00			0.00								0.00
S8465	002	0		29	10	S8465_002_0	4	2	4	3	Tier 2 - Generics	010000	1	2	2			Tier 2 - Generics																							Tier 2 - Generics			Tier 2 - Generics																						Tier 2 - Generics																					
S8465	002	0		29	10	S8465_002_0	4	3	4	3	Tier 3 - Preferred Brands	000001	1	2	2			Tier 3 - Preferred Brands																							Tier 3 - Preferred Brands			Tier 3 - Preferred Brands																						Tier 3 - Preferred Brands																					
S8465	002	0		29	10	S8465_002_0	4	4	4	3	Tier 4 - Brands	000010	3	2	2			Tier 4 - Brands																							Tier 4 - Brands			Tier 4 - Brands																						Tier 4 - Brands																					
S8465	002	0		29	10	S8465_002_0	4	5	4	1	Tier 5 - Specialty	100000	1	1				Tier 5 - Specialty	110000000010100000000	30									30		30									31	Tier 5 - Specialty	2	1	Tier 5 - Specialty	33									33		33									33	Tier 5 - Specialty																					
S8475	001	0		29	10	S8475_001_0	3	1	3	1	Tier 1	001000		2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	15.00								5.00
S8475	001	0		29	10	S8475_001_0	3	5	3	1	Tier 5	100100		1				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	25									25											25	Tier 5																					
S8475	001	0		29	10	S8475_001_0	3	3	3	1	Tier 3	000100		2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	70.00	210.00								70.00		70.00	210.00								70.00
S8475	001	0		29	10	S8475_001_0	3	4	3	1	Tier 4	100100		2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	1	Tier 4	40									40											40	Tier 4																					
S8475	001	0		29	10	S8475_001_0	3	2	3	1	Tier 2	000101		2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	75.00								25.00
S8475	002	0		29	10	S8475_002_0	3	4	4	3	Tier 4	100010	3	2	2			Tier 4																							Tier 4			Tier 4																						Tier 4																					
S8475	002	0		29	10	S8475_002_0	3	3	4	3	Tier 3	100100	3	2	2			Tier 3																							Tier 3			Tier 3																						Tier 3																					
S8475	002	0		29	10	S8475_002_0	3	2	4	3	Tier 2	000101	3	2	2			Tier 2																							Tier 2			Tier 2																						Tier 2																					
S8475	002	0		29	10	S8475_002_0	3	1	4	3	Tier 1	001000	3	2	1		1	Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	15.00								5.00
S8475	002	0		29	10	S8475_002_0	3	5	4	3	Tier 5	100100	3	1	2			Tier 5																							Tier 5			Tier 5																						Tier 5																					
S8475	002	0		29	10	S8475_002_0	3	4	4	1	Tier 4	100010	3	2				Tier 4	110000000010000000000	30									30											31	Tier 4	2	2	Tier 4																						Tier 4	75.00									75.00											75.00
S8475	002	0		29	10	S8475_002_0	3	3	4	1	Tier 3	100100	3	2				Tier 3	111000000010110000000	30	90								30		30								90	31	Tier 3	2	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	150.00								50.00
S8475	002	0		29	10	S8475_002_0	3	2	4	1	Tier 2	000101	3	2				Tier 2	111000000010110000000	30	90								30		30								90	31	Tier 2	2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	75.00								25.00
S8475	002	0		29	10	S8475_002_0	3	1	4	1	Tier 1	001000	3	2				Tier 1	111000000010110000000	30	90								30		30								90	31	Tier 1	2	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	15.00								5.00
S8475	002	0		29	10	S8475_002_0	3	5	4	1	Tier 5	100100	3	1				Tier 5	110000000010000000000	30									30											31	Tier 5	2	1	Tier 5	33									33											33	Tier 5																					
